Extensions für Condition
Folgende Extensions werden im Kontext der Abbildung einer Kodierung nach ICD-10 GM definiert:
Name: Extension-seitenlokalisation (Simplifier Projekt Link)
Beschreibung:
| Dokumentation der Lateralität bei OPS und ICD-10 Codes |
Canonical: http://fhir.de/StructureDefinition/seitenlokalisation
Kontext:
| Condition.code.coding |
| Procedure.code.coding |
| Extension | | | Extension | There are no (further) constraints on this element Element IdShort description Optional Extensions Element Definition Optional Extension Element - found in all resources.
Extension 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()
|
| url | | 1..1 | System.StringFixed Value | Element IdShort description identifies the meaning of the extension Definition Source 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.
System.String Fixed Value
http://fhir.de/StructureDefinition/seitenlokalisation Mappings |
| value[x] | | 1..1 | Binding | Element IdShort description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
A stream of bytes, base64 encoded
https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| valueCoding | | | Coding | Data Type Coding |
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdExtension.value[x].system Identity of the terminology system Definition The 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.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdExtension.value[x].version 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.
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.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdShort 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).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdExtension.value[x].display Representation defined by the system Definition A 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
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.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 | There are no (further) constraints on this element Element IdExtension.value[x].userSelected 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).
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.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- 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 ]
|
Hinweise: Es ist zu beachten, dass laut ICD-10 / OPS GM die Angabe der Seitenlokalisation ein Bestandteil des Codes ist. Somit sollte die Kodierung i.d.R. auf Condition.code.coding bzw. Procedure.code.coding erfolgen. Das bodySite-Element sollte nicht zur Kodierung der Lateralität verwendet werden.
| Hinweis |
Nutzung externer Ressourcen |
|
Das vorliegende Profil enthält Verweise auf CodeSysteme / NamingSystems der Kassenärztliche Bundesvereinigung (KBV). Diese Ressourcen werden nicht als Teil der Deutschen Basisprofile veröffentlicht und sind separat zu Validierungszwecke o.Ä. in die entsprechenden Projekte einzubinden. Siehe fhir.kbv.de. |
Beispiel:
<extension url="http://fhir.de/StructureDefinition/seitenlokalisation" >
<valueCoding>
<system value="https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION" />
<value value="B" />
<display value="beiderseits" />
</valueCoding>
</extension>
Name: Extension-ICD10GMDiagnosesicherheit (Simplifier Projekt Link)
Beschreibung:
Canonical: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Kontext:
| Extension | | | Extension | There are no (further) constraints on this element Element IdShort description Optional Extensions Element Definition Optional Extension Element - found in all resources.
Extension 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()
|
| url | | 1..1 | System.StringFixed Value | Element IdShort description identifies the meaning of the extension Definition Source 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.
System.String Fixed Value
http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Mappings |
| value[x] | | 1..1 | Binding | Element IdShort description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
A stream of bytes, base64 encoded
https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - icd-4:Wenn die Diagnosesicherheit "A (Ausschluss)" verwendet wird, dann muss clinicalStatus leer bleiben und verificationStaus auf "refuted" gesetzt werden.
code!='A' or (%resource.verificationStatus.coding.where(code='refuted').exists() and %resource.clinicalStatus.empty()) - icd-5:Wenn die Diagnosesicherheit "G (Gesichert)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "confirmed" gesetzt werden.
code!='G' or (%resource.clinicalStatus.coding.where(code='active').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists()) - icd-6:Wenn die Diagnosesicherheit "V (Verdacht auf)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "provisional" oder "differential" gesetzt werden.
code!='V' or (%resource.clinicalStatus.coding.where(code='active').exists() and (%resource.verificationStatus.coding.where(code='provisional').exists() or %resource.verificationStatus.coding.where(code='differential').exists())) - icd-7:Wenn die Diagnosesicherheit "Z (Zustand nach)" verwendet wird, dann muss clinicalStatus auf "resolved" und verificationStatus auf "confirmed" gesetzt werden.
code!='Z' or (%resource.clinicalStatus.coding.where(code='resolved').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists())
|
| valueCoding | | | Coding | Data Type Coding |
Constraints:
| icd-4 | warning | Wenn die Diagnosesicherheit "A (Ausschluss)" verwendet wird, dann muss clinicalStatus leer bleiben und verificationStaus auf "refuted" gesetzt werden. | code!='A' or (%resource.verificationStatus.coding.where(code='refuted').exists() and %resource.clinicalStatus.empty()) |
| icd-5 | warning | Wenn die Diagnosesicherheit "G (Gesichert)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "confirmed" gesetzt werden. | code!='G' or (%resource.clinicalStatus.coding.where(code='active').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists()) |
| icd-6 | warning | Wenn die Diagnosesicherheit "V (Verdacht auf)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "provisional" oder "differential" gesetzt werden. | code!='V' or (%resource.clinicalStatus.coding.where(code='active').exists() and (%resource.verificationStatus.coding.where(code='provisional').exists() or %resource.verificationStatus.coding.where(code='differential').exists())) |
| icd-7 | warning | Wenn die Diagnosesicherheit "Z (Zustand nach)" verwendet wird, dann muss clinicalStatus auf "resolved" und verificationStatus auf "confirmed" gesetzt werden. | code!='Z' or (%resource.clinicalStatus.coding.where(code='resolved').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists()) |
Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM
Beispiel:
<extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit">
<valueCoding>
<system value="https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT" />
<code value="G" />
<display value="gesicherte Diagnose" />
</valueCoding>
</extension>
Name: Extension-ICD10GMMehrfachcodierungs-Kennzeichen (Simplifier Projekt Link)
Beschreibung:
Canonical: http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen
Kontext:
| Extension | | | Extension | There are no (further) constraints on this element Element IdShort description Optional Extensions Element Definition Optional Extension Element - found in all resources.
Extension 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()
|
| url | | 1..1 | System.StringFixed Value | Element IdShort description identifies the meaning of the extension Definition Source 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.
System.String Fixed Value
http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Mappings |
| value[x] | | 1..1 | Binding | Element IdShort description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).
A stream of bytes, base64 encoded
MehrfachkodierungsKennzeichen (required) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
|
| valueCoding | | | Coding | Data Type Coding |
| system | Σ | 1..1 | uri | There are no (further) constraints on this element Element IdExtension.value[x].system Identity of the terminology system Definition The 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.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
|
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdExtension.value[x].version 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.
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.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
|
| code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdShort 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).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
|
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdExtension.value[x].display Representation defined by the system Definition A 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
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.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 | There are no (further) constraints on this element Element IdExtension.value[x].userSelected 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).
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.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- 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 ]
|
Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM
Beispiel:
<extension url="http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen">
<valueCoding>
<system value="http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen" />
<code value="*" />
</valueCoding>
</extension>
