Leitfaden Basis DE (R4)

ICD-10-GM (Profil)

ICD-10-GM (Profil)

Condition.code

Profil für die Validierung von Conditions mit ICD-kodierten Diagnosen:

Condition		0..*	Condition	Element Id Condition Short description Detailed information about conditions, problems or diagnoses Definition A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. Data Type Condition Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: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-3: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-6:A resource should have narrative for robust management `text.div.exists()` dom-5:If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` con-5:Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()` con-4:If condition is abated, then clinicalStatus must be either inactive, resolved, or remission `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()` con-3:Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item `clinicalStatus.exists() or verificationStatus='entered-in-error' or category.select($this='problem-list-item').empty()` Mappings rim:Entity. Role, or Act workflow:Event sct-concept:< 243796009 \|Situation with explicit context\| : 246090004 \|Associated finding\| = ( ( < 404684003 \|Clinical finding\| MINUS ( << 420134006 \|Propensity to adverse reactions\| OR << 473010000 \|Hypersensitivity condition\| OR << 79899007 \|Drug interaction\| OR << 69449002 \|Drug action\| OR << 441742003 \|Evaluation finding\| OR << 307824009 \|Administrative status\| OR << 385356007 \|Tumor stage finding\|)) OR < 272379006 \|Event\|) v2:PPR message rim:Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
identifier	Σ	0..*	Identifier	Element Id Condition.identifier Short description External Ids for this condition Definition Business 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. Requirements Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. Comments 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. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Event.identifier w5:FiveWs.identifier rim:.id
clinicalStatus	Σ ?!	0..1	CodeableConceptBinding	Element Id Condition.clinicalStatus Short description active \| recurrence \| relapse \| inactive \| remission \| resolved Definition The clinical status of the condition. Comments 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. Data Type CodeableConcept Binding condition-clinical (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.status w5:FiveWs.status sct-concept:< 303105007 \|Disease phases\| v2:PRB-14 rim:Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
verificationStatus	Σ ?!	0..1	CodeableConceptBinding	Element Id Condition.verificationStatus Short description unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error Definition The verification status to support the clinical status of the condition. Comments 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. Data Type CodeableConcept Binding condition-ver-status (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.status w5:FiveWs.status sct-concept:< 410514004 \|Finding context value\| v2:PRB-13 rim:Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value sct-attr:408729009
category		0..*	CodeableConceptBinding	Element Id Condition.category Short description problem-list-item \| encounter-diagnosis Definition A category assigned to the condition. Comments The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. Data Type CodeableConcept Binding condition-category (extensible) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.class sct-concept:< 404684003 \|Clinical finding\| v2:'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message rim:.code
severity		0..1	CodeableConceptBinding	Element Id Condition.severity Short description Subjective severity of condition Definition A subjective assessment of the severity of the condition as evaluated by the clinician. Comments Coding of the severity with a terminology is preferred, where possible. Data Type CodeableConcept Binding condition-severity (preferred) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.grade sct-concept:< 272141005 \|Severities\| v2:PRB-26 / ABS-3 rim:Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value sct-attr:246112005
code	Σ	1..1	CodeableConcept	Element Id Condition.code Short description Identification of the condition, problem or diagnosis Alternate names type Definition Identification of the condition, problem or diagnosis. Requirements 0..1 to account for primarily narrative only resources. Comments 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. Data Type CodeableConcept Binding condition-code (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.code w5:FiveWs.what[x] sct-concept:code 246090004 \|Associated finding\| (< 404684003 \|Clinical finding\| MINUS << 420134006 \|Propensity to adverse reactions\| MINUS << 473010000 \|Hypersensitivity condition\| MINUS << 79899007 \|Drug interaction\| MINUS << 69449002 \|Drug action\| MINUS << 441742003 \|Evaluation finding\| MINUS << 307824009 \|Administrative status\| MINUS << 385356007 \|Tumor stage finding\|) OR < 413350009 \|Finding with explicit context\| OR < 272379006 \|Event\| v2:PRB-3 rim:.value sct-attr:246090004
coding	Σ	1..*	Coding	Element Id Condition.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding Sliced: Unordered, Open, by system(Value) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` icd-1:Bei Angabe eines Codes in der Haupt-Kreuz-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! `extension('http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz').empty() or code.contains($this.extension('http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz').value.code)` icd-2:Bei Angabe eines Codes in der Stern-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! `extension('http://fhir.de/StructureDefinition/icd-10-gm-stern').empty() or code.contains($this.extension('http://fhir.de/StructureDefinition/icd-10-gm-stern').value.code)` icd-3:Bei Angabe eines Codes in der Ausrufezeichen-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! `extension('http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen').empty() or code.contains($this.extension('http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen').value.code)` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ICD-10-GM	Σ	1..1	Coding-Profil für ICD-10-GMBinding	Element Id Condition.code.coding:ICD-10-GM Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding-Profil für ICD-10-GM Binding TESTICD10GM (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
extension		0..*	Extension	Element Id Condition.code.coding:ICD-10-GM.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May 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. Comments 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. Data Type Extension Sliced: Unordered, Open, by url(Value) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
HauptKreuzCode		0..*	Extension(Coding-Profil für ICD-10-GM)	Element Id Condition.code.coding:ICD-10-GM.extension:HauptKreuzCode Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments 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. Data Type Extension(Coding-Profil für ICD-10-GM) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
SternCode		0..*	Extension(Coding-Profil für ICD-10-GM)	Element Id Condition.code.coding:ICD-10-GM.extension:SternCode Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments 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. Data Type Extension(Coding-Profil für ICD-10-GM) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-stern Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
AusrufezeichenCode		0..*	Extension(Coding-Profil für ICD-10-GM)	Element Id Condition.code.coding:ICD-10-GM.extension:AusrufezeichenCode Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments 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. Data Type Extension(Coding-Profil für ICD-10-GM) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
Diagnosesicherheit		0..1	Extension(Coding)	Element Id Condition.code.coding:ICD-10-GM.extension:Diagnosesicherheit Short description Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments 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. Data Type Extension(Coding) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1:Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim:n/a rim:N/A
system	Σ	1..1	uriFixed Value	Element Id Condition.code.coding:ICD-10-GM.system Short description Canonische ValueSet URL für ICD-10-GM Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments 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. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed Value http://fhir.de/CodeSystem/dimdi/icd-10-gm Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	1..1	string	Element Id Condition.code.coding:ICD-10-GM.version Short description Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie 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. Comments 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	Element Id Condition.code.coding:ICD-10-GM.code Short description Der (ggf. postkoordinierte) ICD-10-Code Definition Der ICD 10 Code ist vollständig anzugeben, ggf. in postkoordinierter Form Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples Postkoordinierter Kreuz-Stern-Code A12.3+ B45.6* Einfacher ICD-Code F17.4 Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	Element Id Condition.code.coding:ICD-10-GM.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	Element Id Condition.code.coding:ICD-10-GM.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements 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. Comments 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. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	Element Id Condition.code.text Short description Plain text representation of the concept Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
bodySite	Σ	0..*	CodeableConcept	Element Id Condition.bodySite Short description Anatomical location, if relevant Definition The anatomical location where this condition manifests itself. Comments 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. Data Type CodeableConcept Binding body-site (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD sct-concept:< 442083009 \|Anatomical or acquired body structure\| rim:.targetBodySiteCode sct-attr:363698007
coding	Σ	0..*	Coding	Element Id Condition.bodySite.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding Sliced: Unordered, Open, by system(Value) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ICD-10-GM-Seitenlokalisation	Σ	0..1	CodingBinding	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding Binding http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
system	Σ	1..1	uri	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments 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. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.version Short description Version of the system - if relevant Definition The 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. Comments 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.code Short description Symbol in syntax defined by the system Definition A 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). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	Element Id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements 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. Comments 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. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	Element Id Condition.bodySite.text Short description Plain text representation of the concept Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	Σ	1..1	Reference(Patient\| Group)	Element Id Condition.subject Short description Who has the condition? Alternate names patient Definition Indicates the patient or group who the condition record is associated with. Requirements Group is typically used for veterinary or public health use cases. Comments 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. Data Type Reference(Patient\| Group) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.subject w5:FiveWs.subject[x] v2:PID-3 rim:.participation[typeCode=SBJ].role[classCode=PAT] w5:FiveWs.subject
encounter	Σ	0..1	Reference(Encounter)	Element Id Condition.encounter Short description Encounter created as part of Definition The Encounter during which this Condition was created or to which the creation of this record is tightly associated. Comments 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". Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Event.context w5:FiveWs.context v2:PV1-19 (+PV1-54) rim:.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
onset[x]	Σ	0..1		Element Id Condition.onset[x] Short description Estimated or actual date, date-time, or age Definition Estimated or actual date or date-time the condition began, in the opinion of the clinician. Comments Age is generally used when the patient reports an age at which the Condition began to occur. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Event.occurrence[x] w5:FiveWs.init v2:PRB-16 rim:.effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
onsetDateTime			dateTime	Data Type dateTime
onsetAge			Age	Data Type Age
onsetPeriod			Period	Data Type Period
onsetRange			Range	Data Type Range
onsetString			string	Data Type string
abatement[x]		0..1		Element Id Condition.abatement[x] Short description When in resolution/remission Definition The 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. Comments 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. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a w5:FiveWs.done[x] rim:.effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
abatementDateTime			dateTime	Data Type dateTime
abatementAge			Age	Data Type Age
abatementPeriod			Period	Data Type Period
abatementRange			Range	Data Type Range
abatementString			string	Data Type string
recordedDate	Σ	0..1	dateTime	Element Id Condition.recordedDate Short description Date record was first recorded Definition The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a w5:FiveWs.recorded v2:REL-11 rim:.participation[typeCode=AUT].time
recorder	Σ	0..1	Reference(Practitioner\| PractitionerRole\| Patient\| RelatedPerson)	Element Id Condition.recorder Short description Who recorded the condition Definition Individual who recorded the record and takes responsibility for its content. Comments 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. Data Type Reference(Practitioner\| PractitionerRole\| Patient\| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.author rim:.participation[typeCode=AUT].role
asserter	Σ	0..1	Reference(Practitioner\| PractitionerRole\| Patient\| RelatedPerson)	Element Id Condition.asserter Short description Person who asserts this condition Definition Individual who is making the condition statement. Comments 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. Data Type Reference(Practitioner\| PractitionerRole\| Patient\| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.source v2:REL-7.1 identifier + REL-7.12 type code rim:.participation[typeCode=INF].role
stage		0..*	BackboneElement	Element Id Condition.stage Short description Stage/grade, usually assessed formally Definition Clinical stage or grade of a condition. May include formal severity assessments. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` con-1:Stage SHALL have summary or assessment `summary.exists() or assessment.exists()` Mappings rim:n/a rim:./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
summary		0..1	CodeableConcept	Element Id Condition.stage.summary Short description Simple summary (disease specific) Definition A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Comments 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. Data Type CodeableConcept Binding condition-stage (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD sct-concept:< 254291000 \|Staging and scales\| v2:PRB-14 rim:.value
assessment		0..*	Reference(ClinicalImpression\| DiagnosticReport\| Observation)	Element Id Condition.stage.assessment Short description Formal record of assessment Definition Reference to a formal record of the evidence on which the staging assessment is based. Comments 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. Data Type Reference(ClinicalImpression\| DiagnosticReport\| Observation) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) rim:.self
type		0..1	CodeableConcept	Element Id Condition.stage.type Short description Kind of staging Definition The kind of staging, such as pathological or clinical staging. Comments 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. Data Type CodeableConcept Binding condition-stage-type (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD rim:./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]
evidence		0..*	BackboneElement	Element Id Condition.evidence Short description Supporting evidence Definition Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. Comments The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` con-2:evidence SHALL have code or details `code.exists() or detail.exists()` Mappings rim:n/a rim:.outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
code	Σ	0..*	CodeableConcept	Element Id Condition.evidence.code Short description Manifestation/symptom Definition A manifestation or symptom that led to the recording of this condition. Comments 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. Data Type CodeableConcept Binding manifestation-or-symptom (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Event.reasonCode w5:FiveWs.why[x] sct-concept:< 404684003 \|Clinical finding\| rim:[code="diagnosis"].value
detail	Σ	0..*	Reference(Resource)	Element Id Condition.evidence.detail Short description Supporting information found elsewhere Definition Links to other relevant information, including pathology reports. Comments 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. Data Type Reference(Resource) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %resource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.why[x] rim:.self
note		0..*	Annotation	Element Id Condition.note Short description Additional information about the Condition Definition Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. Comments 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). Data Type Annotation Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Act workflow:Event.note v2:NTE child of PRB rim:.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value

Condition.code

Bei der Kodierung nach ICD-10(-GM) muss das Element Condition.code mit mindestens einem Coding gefüllt sein, das den Anforderungen der ICD-Kodierung genügt.

Coding		0..*	Coding	Element Id Coding Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Comments 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. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding
system	Σ	1..1	uriFixed Value	Element Id Coding.system Short description Canonische ValueSet URL für ICD-10-GM Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments 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. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed Value http://fhir.de/CodeSystem/dimdi/icd-10-gm Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	1..1	string	Element Id Coding.version Short description Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie 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. Comments 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	Element Id Coding.code Short description Der (ggf. postkoordinierte) ICD-10-Code Definition Der ICD 10 Code ist vollständig anzugeben, ggf. in postkoordinierter Form Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples Postkoordinierter Kreuz-Stern-Code A12.3+ B45.6* Einfacher ICD-Code F17.4 Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	Element Id Coding.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	Element Id Coding.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements 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. Comments 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. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:Sometimes implied by being first rim:CD.codingRationale orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]

Die Angabe der ICD-Version (z.B."2019"), aus der ein Code stammt, ist verpflichtend.

Beispiel: Diagnosesicherheit: "Zustand nach"

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <clinicalStatus>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/condition-clinical" />
            <code value="resolved" />
        </coding>
    </clinicalStatus>
    <verificationStatus>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
            <code value="confirmed" />
        </coding>
    </verificationStatus>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" />
                    <code value="Z" />
                </valueCoding>
            </extension>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F16.1" />
            <display value="Psychische Verhaltensstörung durch Halluzinogene (Akute Intoxikation)" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType":"Condition",
    "meta":{
        "profile": [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "clinicalStatus":{
        "coding": [
            {
                "system":"http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code":"resolved"
            }
        ]
    },
    "verificationStatus":{
        "coding": [
            {
                "system":"http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code":"confirmed"
            }
        ]
    },
    "code":{
        "coding": [
            {
                "extension": [
                    {
                        "url":"http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit",
                        "valueCoding":{
                            "system":"http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit",
                            "code":"Z"
                        }
                    }
                ],
                "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version":"2019",
                "code":"F16.1",
                "display":"Psychische Verhaltensstörung durch Halluzinogene (Akute Intoxikation)"
            }
        ]
    },
    "subject":{
        "reference":"Patient/example"
    }
}

Beispiel: einfacher ICD-Code

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F71" />
            <display value="Mittelgradige Intelligenzminderung" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType":"Condition",
    "meta":{
        "profile": [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code":{
        "coding": [
            {
                "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version":"2019",
                "code":"F71",
                "display":"Mittelgradige Intelligenzminderung"
            }
        ]
    },
    "subject":{
        "reference":"Patient/example"
    }
}

Beispiel: ICD-Code mit Ausrufezeichen-Notation

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="F16.1" />
                </valueCoding>
            </extension>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="U69.32" />
                </valueCoding>
            </extension>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F16.1 U69.32!" />
            <display value="Psychische Verhaltensstörung duch Halluzinogene (Akute Intoxikation) bei intravenösem Konsum" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType":"Condition",
    "meta":{
        "profile": [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code":{
        "coding": [
            {
                "extension": [
                    {
                        "url":"http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz",
                        "valueCoding":{
                            "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version":"2019",
                            "code":"F16.1"
                        }
                    },
                    {
                        "url":"http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen",
                        "valueCoding":{
                            "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version":"2019",
                            "code":"U69.32"
                        }
                    }
                ],
                "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version":"2019",
                "code":"F16.1 U69.32!",
                "display":"Psychische Verhaltensstörung duch Halluzinogene (Akute Intoxikation) bei intravenösem Konsum"
            }
        ]
    },
    "subject":{
        "reference":"Patient/example"
    }
}

Beispiel: ICD-Code mit Kreuz-Stern-Notation

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="E10.30" />
                </valueCoding>
            </extension>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-stern">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="H36.0" />
                </valueCoding>
            </extension>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="E10.30† H36.0*" />
            <display value="Diabetische Retinopathie" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType":"Condition",
    "meta":{
        "profile": [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code":{
        "coding": [
            {
                "extension": [
                    {
                        "url":"http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz",
                        "valueCoding":{
                            "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version":"2019",
                            "code":"E10.30"
                        }
                    },
                    {
                        "url":"http://fhir.de/StructureDefinition/icd-10-gm-stern",
                        "valueCoding":{
                            "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version":"2019",
                            "code":"H36.0"
                        }
                    }
                ],
                "system":"http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version":"2019",
                "code":"E10.30† H36.0*",
                "display":"Diabetische Retinopathie"
            }
        ]
    },
    "subject":{
        "reference":"Patient/example"
    }
}