Leitfaden Basis DE (R4)

Extensions für Condition

Folgende Extensions werden im Kontext der Abbildung einer Kodierung nach ICD-10 GM definiert:

Name: Extension-seitenlokalisation (Simplifier Projekt Link)

Beschreibung:

description
Dokumentation der Lateralität bei OPS und ICD-10 Codes

description

Dokumentation der Lateralität bei OPS und ICD-10 Codes

Canonical: http://fhir.de/StructureDefinition/seitenlokalisation

Kontext:

expression
Condition.code.coding
Procedure.code.coding

Extension	I		Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type 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()` Mappings rim:n/a rim:N/A
url		1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments 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. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/seitenlokalisation Mappings rim:N/A
value[x]		1..1	Binding	Element Id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Binding 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())` Mappings rim:n/a rim:N/A
valueCoding			Coding	Data Type Coding
system	Σ	1..1	uri	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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 ]

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:

expression
Condition.code.coding

Extension	I		Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type 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()` Mappings rim:n/a rim:N/A
url		1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments 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. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Mappings rim:N/A
value[x]	I	1..1	Binding	Element Id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Binding 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())` Mappings rim:n/a rim:N/A
valueCoding			Coding	Data Type Coding

Constraints:

key	severity	human	expression
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 - 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:

expression
Condition.code.coding

Extension	I		Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type 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()` Mappings rim:n/a rim:N/A
url		1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments 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. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Mappings rim:N/A
value[x]		1..1	Binding	Element Id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Binding MehrfachkodierungsKennzeichen (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:N/A
valueCoding			Coding	Data Type Coding
system	Σ	1..1	uri	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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	There are no (further) constraints on this element Element Id Extension.value[x].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 ]

Hinweise: Siehe Kodierungshinweise für ICD-10 GM - 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>