MII IG Molekulares Tumorboard DE v2025

Follow-Up: ClinicalImpression

Inhalt

Dieses Profil beschreibt Informationen über den administrativen Vorgang "Follow-Up" und den dabei eingeholten Informationen. Im Zuge dieses Follow-Up Prozesses werden die durchgeführten Therapien (MII_PR_MTB_Systemische_Therapie) inkl nachfolgender Therapie-Response und ggfs. deren Kostenübernahmen (MII_PR_MTB_Antrag_Kostenuebernahme & MII_PR_MTB_Antwort_Kostenuebernahme) dokumentiert. Zusätzlich ist hier der Status des Therapieplans ClinicalImpression.investigation und eine Begründung bei Nicht-Durchführung ClinicalImpression.statusReason enthalten.

Verknüpfungen zu anderen Ressourcen

Die Follow-up ClinicalImpression verweisen alle unter ClinicalImpression.previous auf die Behandlungsepisode

Zeitliche Zuordnung im Verlauf

Name	Status	Version	Canonical	Basis
MII_PR_MTB_Follow_Up_ClinicalImpression	draft	2024.0.0-ballot	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression	http://hl7.org/fhir/StructureDefinition/ClinicalImpression

Inhalt

MII_PR_MTB_Follow_Up_ClinicalImpression (ClinicalImpression)	I		ClinicalImpression	There are no (further) constraints on this element Element id ClinicalImpression Short description A clinical assessment performed when planning treatments and management strategies for a patient Definition A record of a clinical assessment performed to determine what problem(s) may affect the patient and before planning the treatments or management strategies that are best to manage a patient's condition. Assessments are often 1:1 with a clinical consultation / encounter, but this varies greatly depending on the clinical workflow. This resource is called "ClinicalImpression" rather than "ClinicalAssessment" to avoid confusion with the recording of assessment tools such as Apgar score. Data type ClinicalImpression Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.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-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-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event v2: Partial mapping for problem evaluation
id	Σ	0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	S Σ	0..1	Meta	There are no (further) constraints on this element Element id ClinicalImpression.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.meta.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.meta.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) Extensions are always sliced by (at least) url 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
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id ClinicalImpression.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id ClinicalImpression.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
source	Σ	0..1	uri	There are no (further) constraints on this element Element id ClinicalImpression.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id ClinicalImpression.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id ClinicalImpression.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id ClinicalImpression.meta.tag Short description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id ClinicalImpression.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id ClinicalImpression.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id ClinicalImpression.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id ClinicalImpression.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.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 resource. 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 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
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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 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
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id ClinicalImpression.identifier Short description Business identifier Definition Business identifiers assigned to this clinical impression 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 clinical impression 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 workflow: Event.identifier w5: FiveWs.identifier v2: PID-3
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id ClinicalImpression.status Short description in-progress \| completed \| entered-in-error Definition Identifies the workflow status of the assessment. Comments This element is labeled as a modifier because the status contains the code entered-in-error that marks the clinical impression as not currently valid. Data type code Binding The workflow state of a clinical impression. ClinicalImpressionStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status v2: PRB-14
statusReason	S	0..1	CodeableConcept	Element id ClinicalImpression.statusReason Short description Grund Nicht-Umsetzung Alternate names Suspended Reason, Cancelled Reason Definition Grund für die Nicht-Umsetzung des gesamten Therapieplans Comments This is generally only used for "exception" statuses such as "not-done", "suspended" or "cancelled". [distinct reason codes for different statuses can be enforced using invariants if they are universal bindings]. Data type CodeableConcept Binding Codes identifying the reason for the current state of a clinical impression. (unbound) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.statusReason rim: .inboundRelationship[typeCode=SUBJ].source[classCode=CACT, moodCode=EVN].reasonCOde
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.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) Extensions are always sliced by (at least) url 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
coding	Σ	1..1	Coding	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.coding.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.coding.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) Extensions are always sliced by (at least) url 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
system	Σ	0..1	uriPattern	Element id ClinicalImpression.statusReason.coding.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())` Pattern https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-systemische-therapie-status-grund Mappings 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 ClinicalImpression.statusReason.coding.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 v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	codeBinding	Element id ClinicalImpression.statusReason.coding.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. Data type code Binding MII_VS_MTB_Follow_Up_Grund_Nicht_Umsetzung (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings 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 ClinicalImpression.statusReason.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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings 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 ClinicalImpression.statusReason.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 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	There are no (further) constraints on this element Element id ClinicalImpression.statusReason.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 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
code	S Σ	1..1	CodeableConcept	Element id ClinicalImpression.code Short description Follow-Up Alternate names type Definition Follow-Up als Prozess des Einholens von Informationen über durchgeführte Therapien & Kostenuebernahmen Comments This is present as a place-holder only and may be removed based on feedback/work group opinion. Data type CodeableConcept Binding Identifies categories of clinical impressions. This is a place-holder only. It may be removed. (unbound) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.code w5: FiveWs.what[x]
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.code.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.code.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) Extensions are always sliced by (at least) url 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
coding	Σ	0..*	CodingPattern	Element id ClinicalImpression.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://snomed.info/sct", "code": "390906007", "display": "Follow-up encounter (procedure)" } Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.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 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
description	Σ	0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.description Short description Why/how the assessment was performed Definition A summary of the context and/or cause of the assessment - why / where it was performed, and what patient events/status prompted it. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
subject	S Σ	1..1	Reference(Patient \| Group)	There are no (further) constraints on this element Element id ClinicalImpression.subject Short description Patient or group assessed Definition The patient or group of individuals assessed as part of this record. Requirements Group is typically for veterinary and/or public health purposes. Data type Reference(Patient \| Group) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 w5: FiveWs.subject
encounter	Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id ClinicalImpression.encounter Short description Encounter created as part of Definition The Encounter during which this ClinicalImpression 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. Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.context w5: FiveWs.context
effective[x]	S Σ	0..1		Element id ClinicalImpression.effective[x] Short description Erfassungsdatum Definition Erfassungsdatum Durchführung Follow-Up Comments This SHOULD be accurate to at least the minute, though some assessments only have a known date. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: PRB-2
effectiveDateTime			dateTime	Data type dateTime
date	Σ	0..1	dateTime	There are no (further) constraints on this element Element id ClinicalImpression.date Short description When the assessment was documented Definition Indicates when the documentation of the assessment was complete. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.recorded
assessor	Σ	0..1	Reference(Practitioner \| PractitionerRole)	There are no (further) constraints on this element Element id ClinicalImpression.assessor Short description The clinician performing the assessment Definition The clinician performing the assessment. Data type Reference(Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer.actor w5: FiveWs.author v2: ROL-4
previous	S	1..1	Reference(MII_PR_MTB_Behandlungsepisode)	Element id ClinicalImpression.previous Short description MTB-Behandlungsepisode Definition MTB-Behandlungsepisode, auf die sich das Follow-Up bezieht Comments It is always likely that multiple previous assessments exist for a patient. The point of quoting a previous assessment is that this assessment is relative to it (see resolved). Data type Reference(MII_PR_MTB_Behandlungsepisode) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
problem	Σ	0..*	Reference(Condition \| AllergyIntolerance)	There are no (further) constraints on this element Element id ClinicalImpression.problem Short description Relevant impressions of patient state Definition A list of the relevant problems/conditions for a patient. Comments e.g. The patient is a pregnant, has congestive heart failure, has an ‎Adenocarcinoma, and is allergic to penicillin. Data type Reference(Condition \| AllergyIntolerance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.why[x] v2: PRB-3 / IAM-7
investigation	S	0..*	BackboneElement	Element id ClinicalImpression.investigation Short description Status Follow-Up Definition Status des Therapieplans im Hinblick auf das Follow-Up Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.investigation.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.investigation.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 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
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.investigation.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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 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
code		1..1	CodeableConcept	There are no (further) constraints on this element Element id ClinicalImpression.investigation.code Short description A name/code for the set Definition A name/code for the group ("set") of investigations. Typically, this will be something like "signs", "symptoms", "clinical", "diagnostic", but the list is not constrained, and others such groups such as (exposure\|family\|travel\|nutritional) history may be used. Data type CodeableConcept Binding A name/code for a set of investigations. InvestigationType (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.investigation.code.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.investigation.code.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) Extensions are always sliced by (at least) url 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
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element id ClinicalImpression.investigation.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.investigation.code.coding.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.investigation.code.coding.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) Extensions are always sliced by (at least) url 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
system	Σ	0..1	uriPattern	Element id ClinicalImpression.investigation.code.coding.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())` Pattern https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status Mappings 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 ClinicalImpression.investigation.code.coding.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 v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	codeBinding	Element id ClinicalImpression.investigation.code.coding.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. Data type code Binding MII_VS_MTB_Follow_Up_Status (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings 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 ClinicalImpression.investigation.code.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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings 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 ClinicalImpression.investigation.code.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 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	There are no (further) constraints on this element Element id ClinicalImpression.investigation.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 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
item		0..*	Reference(Observation \| QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy \| Media)	There are no (further) constraints on this element Element id ClinicalImpression.investigation.item Short description Record of a specific investigation Definition A record of a specific investigation that was undertaken. Comments Most investigations are observations of one kind or another but some other specific types of data collection resources can also be used. Data type Reference(Observation \| QuestionnaireResponse \| FamilyMemberHistory \| DiagnosticReport \| RiskAssessment \| ImagingStudy \| Media) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX-21
protocol		0..*	uri	There are no (further) constraints on this element Element id ClinicalImpression.protocol Short description Clinical Protocol followed Definition Reference to a specific published clinical protocol that was followed during this assessment, and/or that provides evidence in support of the diagnosis. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
summary		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.summary Short description Summary of the assessment Definition A text summary of the investigations and the diagnosis. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX
finding		0..*	BackboneElement	There are no (further) constraints on this element Element id ClinicalImpression.finding Short description Possible or likely findings and diagnoses Definition Specific findings or diagnoses that were considered likely or relevant to ongoing treatment. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.finding.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.finding.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 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
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id ClinicalImpression.finding.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. 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 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
itemCodeableConcept		0..1	CodeableConcept	There are no (further) constraints on this element Element id ClinicalImpression.finding.itemCodeableConcept Short description What was found Definition Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions. Data type CodeableConcept Binding Identification of the Condition or diagnosis. Condition/Problem/DiagnosisCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX
itemReference		0..1	Reference(Condition \| Observation \| Media)	There are no (further) constraints on this element Element id ClinicalImpression.finding.itemReference Short description What was found Definition Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions. Data type Reference(Condition \| Observation \| Media) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX
basis		0..1	string	There are no (further) constraints on this element Element id ClinicalImpression.finding.basis Short description Which investigations support finding Definition Which investigations support finding or diagnosis. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
prognosisCodeableConcept		0..*	CodeableConcept	There are no (further) constraints on this element Element id ClinicalImpression.prognosisCodeableConcept Short description Estimate of likely outcome Definition Estimate of likely outcome. Data type CodeableConcept Binding Prognosis or outlook findings. ClinicalImpressionPrognosis (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: PRB-22
prognosisReference		0..*	Reference(RiskAssessment)	There are no (further) constraints on this element Element id ClinicalImpression.prognosisReference Short description RiskAssessment expressing likely outcome Definition RiskAssessment expressing likely outcome. Data type Reference(RiskAssessment) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
supportingInfo	S	0..*	Reference(Resource)	Element id ClinicalImpression.supportingInfo Short description Information supporting the clinical impression Definition Information supporting the clinical impression. Data type Reference(Resource) Sliced: Unordered, Open, by $this.resolve()(Type) Slice für die durch das Follow-Up gewonnenen Informationen Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
UmgesetzteTherapien	S	0..*	Reference(Procedure)	Element id ClinicalImpression.supportingInfo:UmgesetzteTherapien Short description Umgesetzte Therapien Definition Umgesetzte Therapien mit oder auch ohne Bezug auf die MTB-Empfehlungen Data type Reference(Procedure) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
AntraegeKostenuebernahme	S	0..*	Reference(Claim)	Element id ClinicalImpression.supportingInfo:AntraegeKostenuebernahme Short description Anträge Kostenübernahme Definition Anträge Kostenübernahme für die empfohlenen Therapien Data type Reference(Claim) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
AntwortenKostenuebernahme		0..*	Reference(ClaimResponse)	Element id ClinicalImpression.supportingInfo:AntwortenKostenuebernahme Short description Antworten Kostenübernahme Definition Antworten der Versicherungen auf die Anträge zur Kostenübernahme Data type Reference(ClaimResponse) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
note		0..*	Annotation	There are no (further) constraints on this element Element id ClinicalImpression.note Short description Comments made about the ClinicalImpression Definition Commentary about the impression, typically recorded after the impression itself was made, though supplemental notes by the original author could also appear. Comments Don't use this element for content that should more properly appear as one of the specific elements of the impression. Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.note

Follow-Up als Prozess des Einholens von Informationen über durchgeführte Therapien & Kostenuebernahmen

Feldname	Kurzbeschreibung
ClinicalImpression.meta
ClinicalImpression.meta.profile
ClinicalImpression.status
ClinicalImpression.statusReason	Grund Nicht-Umsetzung
ClinicalImpression.statusReason.coding.code
ClinicalImpression.code	Follow-Up
ClinicalImpression.subject
ClinicalImpression.effective[x]	Erfassungsdatum
ClinicalImpression.previous	MTB-Behandlungsepisode
ClinicalImpression.investigation	Status Follow-Up
ClinicalImpression.supportingInfo
ClinicalImpression.supportingInfo:UmgesetzteTherapien	Umgesetzte Therapien
ClinicalImpression.supportingInfo:AntraegeKostenuebernahme	Anträge Kostenübernahme

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-mtb-follow-up-clinicalimpression" />
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression" />
    <version value="2024.0.0-ballot" />
    <name value="MII_PR_MTB_Follow_Up_ClinicalImpression" />
    <title value="MII PR MTB Clinical Impresssion" />
    <status value="draft" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Follow-Up als Prozess des Einholens von Informationen &#252;ber durchgef&#252;hrte Therapien &amp; Kostenuebernahmen" />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="ClinicalImpression" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ClinicalImpression" />
    <derivation value="constraint" />
    <differential>
        <element id="ClinicalImpression.meta">
            <path value="ClinicalImpression.meta" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.meta.profile">
            <path value="ClinicalImpression.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.status">
            <path value="ClinicalImpression.status" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.statusReason">
            <path value="ClinicalImpression.statusReason" />
            <short value="Grund Nicht-Umsetzung" />
            <definition value="Grund f&#252;r die Nicht-Umsetzung des gesamten Therapieplans" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.statusReason.coding">
            <path value="ClinicalImpression.statusReason.coding" />
            <min value="1" />
            <max value="1" />
        </element>
        <element id="ClinicalImpression.statusReason.coding.system">
            <path value="ClinicalImpression.statusReason.coding.system" />
            <patternUri value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-systemische-therapie-status-grund" />
        </element>
        <element id="ClinicalImpression.statusReason.coding.code">
            <path value="ClinicalImpression.statusReason.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-follow-up-grund-nicht-umsetzung" />
            </binding>
        </element>
        <element id="ClinicalImpression.code">
            <path value="ClinicalImpression.code" />
            <short value="Follow-Up" />
            <definition value="Follow-Up als Prozess des Einholens von Informationen &#252;ber durchgef&#252;hrte Therapien &amp; Kostenuebernahmen" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.code.coding">
            <path value="ClinicalImpression.code.coding" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
                <code value="390906007" />
                <display value="Follow-up encounter (procedure)" />
            </patternCoding>
        </element>
        <element id="ClinicalImpression.subject">
            <path value="ClinicalImpression.subject" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.effective[x]">
            <path value="ClinicalImpression.effective[x]" />
            <short value="Erfassungsdatum" />
            <definition value="Erfassungsdatum Durchf&#252;hrung Follow-Up" />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.previous">
            <path value="ClinicalImpression.previous" />
            <short value="MTB-Behandlungsepisode" />
            <definition value="MTB-Behandlungsepisode, auf die sich das Follow-Up bezieht" />
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-behandlungsepisode" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.investigation">
            <path value="ClinicalImpression.investigation" />
            <short value="Status Follow-Up" />
            <definition value="Status des Therapieplans im Hinblick auf das Follow-Up" />
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.investigation.code.coding.system">
            <path value="ClinicalImpression.investigation.code.coding.system" />
            <patternUri value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status" />
        </element>
        <element id="ClinicalImpression.investigation.code.coding.code">
            <path value="ClinicalImpression.investigation.code.coding.code" />
            <binding>
                <strength value="required" />
                <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-follow-up-status" />
            </binding>
        </element>
        <element id="ClinicalImpression.supportingInfo">
            <path value="ClinicalImpression.supportingInfo" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this.resolve()" />
                </discriminator>
                <description value="Slice f&#252;r die durch das Follow-Up gewonnenen Informationen" />
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.supportingInfo:UmgesetzteTherapien">
            <path value="ClinicalImpression.supportingInfo" />
            <sliceName value="UmgesetzteTherapien" />
            <short value="Umgesetzte Therapien" />
            <definition value="Umgesetzte Therapien mit oder auch ohne Bezug auf die MTB-Empfehlungen" />
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Procedure" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.supportingInfo:AntraegeKostenuebernahme">
            <path value="ClinicalImpression.supportingInfo" />
            <sliceName value="AntraegeKostenuebernahme" />
            <short value="Antr&#228;ge Kosten&#252;bernahme" />
            <definition value="Antr&#228;ge Kosten&#252;bernahme f&#252;r die empfohlenen Therapien" />
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Claim" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ClinicalImpression.supportingInfo:AntwortenKostenuebernahme">
            <path value="ClinicalImpression.supportingInfo" />
            <sliceName value="AntwortenKostenuebernahme" />
            <short value="Antworten Kosten&#252;bernahme" />
            <definition value="Antworten der Versicherungen auf die Antr&#228;ge zur Kosten&#252;bernahme" />
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/ClaimResponse" />
            </type>
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-mtb-follow-up-clinicalimpression",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression",
    "version": "2024.0.0-ballot",
    "name": "MII_PR_MTB_Follow_Up_ClinicalImpression",
    "title": "MII PR MTB Clinical Impresssion",
    "status": "draft",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Follow-Up als Prozess des Einholens von Informationen über durchgeführte Therapien & Kostenuebernahmen",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "ClinicalImpression",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "ClinicalImpression.meta",
                "path": "ClinicalImpression.meta",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.meta.profile",
                "path": "ClinicalImpression.meta.profile",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.status",
                "path": "ClinicalImpression.status",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.statusReason",
                "path": "ClinicalImpression.statusReason",
                "short": "Grund Nicht-Umsetzung",
                "definition": "Grund für die Nicht-Umsetzung des gesamten Therapieplans",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.statusReason.coding",
                "path": "ClinicalImpression.statusReason.coding",
                "min": 1,
                "max": "1"
            },
            {
                "id": "ClinicalImpression.statusReason.coding.system",
                "path": "ClinicalImpression.statusReason.coding.system",
                "patternUri": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-systemische-therapie-status-grund"
            },
            {
                "id": "ClinicalImpression.statusReason.coding.code",
                "path": "ClinicalImpression.statusReason.coding.code",
                "min": 1,
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-follow-up-grund-nicht-umsetzung"
                }
            },
            {
                "id": "ClinicalImpression.code",
                "path": "ClinicalImpression.code",
                "short": "Follow-Up",
                "definition": "Follow-Up als Prozess des Einholens von Informationen über durchgeführte Therapien & Kostenuebernahmen",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.code.coding",
                "path": "ClinicalImpression.code.coding",
                "patternCoding": {
                    "code": "390906007",
                    "system": "http://snomed.info/sct",
                    "display": "Follow-up encounter (procedure)"
                }
            },
            {
                "id": "ClinicalImpression.subject",
                "path": "ClinicalImpression.subject",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.effective[x]",
                "path": "ClinicalImpression.effective[x]",
                "short": "Erfassungsdatum",
                "definition": "Erfassungsdatum Durchführung Follow-Up",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.previous",
                "path": "ClinicalImpression.previous",
                "short": "MTB-Behandlungsepisode",
                "definition": "MTB-Behandlungsepisode, auf die sich das Follow-Up bezieht",
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-behandlungsepisode"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.investigation",
                "path": "ClinicalImpression.investigation",
                "short": "Status Follow-Up",
                "definition": "Status des Therapieplans im Hinblick auf das Follow-Up",
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.investigation.code.coding.system",
                "path": "ClinicalImpression.investigation.code.coding.system",
                "patternUri": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status"
            },
            {
                "id": "ClinicalImpression.investigation.code.coding.code",
                "path": "ClinicalImpression.investigation.code.coding.code",
                "binding": {
                    "strength": "required",
                    "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/ValueSet/mii-vs-mtb-follow-up-status"
                }
            },
            {
                "id": "ClinicalImpression.supportingInfo",
                "path": "ClinicalImpression.supportingInfo",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this.resolve()"
                        }
                    ],
                    "rules": "open",
                    "description": "Slice für die durch das Follow-Up gewonnenen Informationen",
                    "ordered": false
                },
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.supportingInfo:UmgesetzteTherapien",
                "path": "ClinicalImpression.supportingInfo",
                "sliceName": "UmgesetzteTherapien",
                "short": "Umgesetzte Therapien",
                "definition": "Umgesetzte Therapien mit oder auch ohne Bezug auf die MTB-Empfehlungen",
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Procedure"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.supportingInfo:AntraegeKostenuebernahme",
                "path": "ClinicalImpression.supportingInfo",
                "sliceName": "AntraegeKostenuebernahme",
                "short": "Anträge Kostenübernahme",
                "definition": "Anträge Kostenübernahme für die empfohlenen Therapien",
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Claim"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ClinicalImpression.supportingInfo:AntwortenKostenuebernahme",
                "path": "ClinicalImpression.supportingInfo",
                "sliceName": "AntwortenKostenuebernahme",
                "short": "Antworten Kostenübernahme",
                "definition": "Antworten der Versicherungen auf die Anträge zur Kostenübernahme",
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/ClaimResponse"
                        ]
                    }
                ]
            }
        ]
    }
}

MII PR MTB Clinical Impresssion

Mapping Datensatz zu FHIR

Datensatz	Erklaerung	FHIR
Follow-Up nach DNPM	Follow-Up nach DNPM	ClinicalImpression
Erfassungsdatum	Erfassungsdatum Durchführung Follow-Up	ClinicalImpression.effective
Follow-Up Status	Follow-Up Status	ClinicalImpression.status
GrundNichtUmsetzung	Grund für die Nicht-Umsetzung des gesamten Therapieplans. Wird entweder evaluiert, wenn Patient ein zweites mal im MTB vorgestellt wird oder Patient verstorben ist.	ClinicalImpression.statusReason
Systemische Therapie nach DNPM	Systemische Therapie nach DNPM	ClinicalImpression.supportingInfo[UmgesetzteTherapien]
Kostenuebernahme Follow-Up	Kostenuebernahme Follow-Up	ClinicalImpression.supportingInfo[AntraegeKostenuebernahme]
Antwort Kostenuebernahme Follow-Up	Antwort Kostenuebernahme Follow-Up	ClinicalImpression.supportingInfo[AntwortKostenuebernahme]

Suchparameter

Folgende Suchparameter sind für das Modul MTB relevant, auch in Kombination:

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?_id=12345

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "status" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?status=completed

Anwendungshinweise: Weitere Informationen zur Suche nach "ClinicalImpression.status" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "statusReason" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?statusReson=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-systemische-therapie-status-grund|payment-refused

Anwendungshinweise: Weitere Informationen zur Suche nach "ClinicalImpression.statusReason" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "subject" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?subject=Patient/example

Anwendungshinweise: Weitere Informationen zur Suche nach "ClinicalImpression.subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "investigation" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?investigation=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status|ongoing

Anwendungshinweise: Weitere Informationen zur Suche nach "ClinicalImpression.investigation" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "supporting-info" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?supporting-info=MII_PR_MTB_Systemische_Therapie/example

Anwendungshinweise: Weitere Informationen zur Suche nach "ClinicalImpression.supportingInfo" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".

Beispiele

Tabelle
JSON

ClinicalImpression.id[0]	MII-EXA-MTB-Follow-Up-ClinicalImpression-Beispiel-1
ClinicalImpression.meta[0].profile[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression
ClinicalImpression.status[0]	completed
ClinicalImpression.code[0].coding[0].system[0]	http://snomed.info/sct
ClinicalImpression.code[0].coding[0].code[0]	390906007
ClinicalImpression.code[0].coding[0].display[0]	Follow-up encounter (procedure)
ClinicalImpression.subject[0].reference[0]	Patient/PatientExample
ClinicalImpression.effective[0]	2024-07-07
ClinicalImpression.previous[0].reference[0]	ClinicalImpression/mii-exa-mtb-kim-musterperson-behandlungsepisode
ClinicalImpression.investigation[0].code[0].coding[0].system[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status
ClinicalImpression.investigation[0].code[0].coding[0].code[0]	ongoing
ClinicalImpression.supportingInfo[0].reference[0]	MII_PR_MTB_Systemische_Therapie/Example
ClinicalImpression.supportingInfo[1].reference[0]	MII_PR_MTB_Antrag_Kostenuebernahme/Example
ClinicalImpression.supportingInfo[2].reference[0]	MII_PR_MTB_Antwort_Kostenuebernahme/Example

{
    "resourceType": "ClinicalImpression",
    "id": "MII-EXA-MTB-Follow-Up-ClinicalImpression-Beispiel-1",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-follow-up-clinicalimpression"
        ]
    },
    "code": {
        "coding":  [
            {
                "code": "390906007",
                "system": "http://snomed.info/sct",
                "display": "Follow-up encounter (procedure)"
            }
        ]
    },
    "investigation":  [
        {
            "code": {
                "coding":  [
                    {
                        "code": "ongoing",
                        "system": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/CodeSystem/mii-cs-mtb-follow-up-status"
                    }
                ]
            }
        }
    ],
    "supportingInfo":  [
        {
            "reference": "MII_PR_MTB_Systemische_Therapie/Example"
        },
        {
            "reference": "MII_PR_MTB_Antrag_Kostenuebernahme/Example"
        },
        {
            "reference": "MII_PR_MTB_Antwort_Kostenuebernahme/Example"
        }
    ],
    "subject": {
        "reference": "Patient/PatientExample"
    },
    "status": "completed",
    "effectiveDateTime": "2024-07-07",
    "previous": {
        "reference": "ClinicalImpression/mii-exa-mtb-kim-musterperson-behandlungsepisode"
    }
}