MII IG Modul Seltene Erkrankungen

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

Meta

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

implicitRules

Σ ?!

0..1

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

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)

Binding extensions

maxValueSet	AllLanguages

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

0..*

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

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

?! C

0..*

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

Data type

ClinicalImpressionStatus (required)

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

S 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

Element id

ClinicalImpression.status

Short description

Status der klinischen Beurteilung

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.

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

0..1

There are no (further) constraints on this element

Element id

ClinicalImpression.statusReason

Short description

Reason for current status

Alternate names

Suspended Reason, Cancelled Reason

Definition

Captures the reason for the current state of the ClinicalImpression.

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

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

code

S Σ

0..1

Element id

ClinicalImpression.code

Short description

Art der klinischen Beurteilung

Alternate names

type

Definition

Kategorisiert die Art der klinischen Beurteilung, die erstellt wird

Comments

This is present as a place-holder only and may be removed based on feedback/work group opinion.

Data type

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]
SE-LogicalModel: AnamneseUndDiagnostik.Untersuchungsanlass

description

S Σ

0..1

Element id

ClinicalImpression.description

Short description

Zusammenfassung der klinischen Beurteilung

Definition

Eine Zusammenfassung der Beurteilung mit relevanter klinischer Begründung

Data type

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)

Element id

ClinicalImpression.subject

Short description

Patient, der beurteilt wird

Definition

Referenz auf den Patienten, für den diese klinische Beurteilung erstellt wird

Requirements

Group is typically for veterinary and/or public health purposes.

Data type

Reference(Patient)

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
SE-LogicalModel: Patient

encounter

S Σ

0..1

Reference(Encounter)

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
SE-LogicalModel: AnamneseUndDiagnostik.Untersuchungsdatum

effective[x]

S Σ

0..1

Element id

ClinicalImpression.effective[x]

Short description

Zeitpunkt der Beurteilung

Definition

Der Zeitpunkt oder Zeitraum, über den die klinische Beurteilung gebildet wurde

Comments

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

Slicing

Unordered, Open, by $this(Type)

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

0..1

Element id

ClinicalImpression.effective[x]:effectiveDateTime

Short description

Time of assessment

Definition

The point in time or period over which the subject was assessed.

Comments

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

Data type

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
SE-LogicalModel: AnamneseUndDiagnostik.Untersuchungsdatum

effectivePeriod

0..1

Period

Element id

ClinicalImpression.effective[x]:effectivePeriod

Short description

Time of assessment

Definition

The point in time or period over which the subject was assessed.

Comments

This SHOULD be accurate to at least the minute, though some assessments only have a known date.

Data type

Period

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

0..1

There are no (further) constraints on this element

Element id

ClinicalImpression.effective[x]:effectivePeriod.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

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

ClinicalImpression.effective[x]:effectivePeriod.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

Data type

Slicing

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

start

Σ C

0..1

Element id

ClinicalImpression.effective[x]:effectivePeriod.start

Short description

Starting time with inclusive boundary

Definition

The start of the period. The boundary is inclusive.

Comments

If the low element is missing, the meaning is that the low boundary is not known.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.1
rim: ./low
SE-LogicalModel: AnamneseUndDiagnostik.Untersuchungsdatum

end

Σ C

0..1

Element id

ClinicalImpression.effective[x]:effectivePeriod.end

Short description

End time with inclusive boundary, if not ongoing

Definition

The end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time.

Comments

The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.

Meaning when missing

If the end of the period is missing, it means that the period is ongoing

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: per-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: DR.2
rim: ./high
SE-LogicalModel: AnamneseUndDiagnostik.Untersuchungsdatum

date

S Σ

0..1

Element id

ClinicalImpression.date

Short description

Wann die Beurteilung dokumentiert wurde

Definition

Gibt an, wann die klinische Beurteilung dokumentiert wurde

Data type

Reference(ClinicalImpression)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.recorded

assessor

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

0..1

There are no (further) constraints on this element

Element id

ClinicalImpression.previous

Short description

Reference to last assessment

Definition

A reference to the last assessment that was conducted on this patient. Assessments are often/usually ongoing in nature; a care provider (practitioner or team) will make new assessments on an ongoing basis as new data arises or the patient's conditions changes.

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(ClinicalImpression)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

problem

S Σ

0..*

Reference(Condition | AllergyIntolerance)

Element id

ClinicalImpression.problem

Short description

Relevante Probleme/Erkrankungen

Definition

Eine Liste der relevanten Probleme/Erkrankungen für diesen Patienten, die die klinische Beurteilung beeinflussen können

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
SE-LogicalModel: AnamneseUndDiagnostik.KlinischeDiagnose

investigation

0..*

Element id

ClinicalImpression.investigation

Short description

Eine oder mehrere Untersuchungsserien

Definition

One or more sets of investigations (signs, symptoms, etc.). The actual grouping of investigations varies greatly depending on the type and context of the assessment. These investigations may include data generated during the assessment process, or data previously generated and recorded that is pertinent to the outcomes.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

0..1

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

Mappings

rim: n/a

extension

0..*

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

Comments

Data type

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 ?! C

0..*

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

Comments

Data type

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

Element id

ClinicalImpression.investigation.code

Short description

Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde

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

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())

Mappings

SE-LogicalModel: AnamneseUndDiagnostik.MethodeDiagnosestellung

item

0..*

Reference(Observation | QuestionnaireResponse | FamilyMemberHistory | DiagnosticReport | RiskAssessment)

Element id

ClinicalImpression.investigation.item

Short description

Unters

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)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: OBX-21
SE-LogicalModel: AnamneseUndDiagnostik.Phaenotypisierung

protocol

0..*

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

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

summary

0..1

Element id

ClinicalImpression.summary

Short description

Zusammenfassung der klinischen Beurteilung

Definition

Eine Textzusammenfassung der Beurteilung mit hervorgehobenen wichtigsten Aspekten

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: OBX

finding

0..*

Element id

ClinicalImpression.finding

Short description

Klinische Befunde der Untersuchung

Definition

Klinische Befunde, die auf Basis der Untersuchungen festgestellt wurden

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

0..1

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

Mappings

rim: n/a

extension

0..*

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

Comments

Data type

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 ?! C

0..*

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

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

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

CodeableConceptBinding

Element id

ClinicalImpression.finding.itemCodeableConcept

Short description

Klinischer Befund

Definition

Specific text or code for finding or diagnosis, which may include ruled-out or resolved conditions.

Data type

HPOPhenotypicObservationCodes (extensible)

Binding

Identification of the Condition or diagnosis.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: OBX
SE-LogicalModel: AnamneseUndDiagnostik.Phaenotypisierung.HPOTerm

itemReference

0..1

Reference(Condition | Observation)

Element id

ClinicalImpression.finding.itemReference

Short description

Referenz auf klinischen Befund

Definition

Specific reference for finding or diagnosis, which may include ruled-out or resolved conditions.

Data type

Reference(Condition | Observation)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: OBX
SE-LogicalModel: AnamneseUndDiagnostik.Phaenotypisierung

basis

0..1

Element id

ClinicalImpression.finding.basis

Short description

Grundlage für den Befund

Definition

Which investigations support finding or diagnosis.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

prognosisCodeableConcept

0..*

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

ClinicalImpressionPrognosis (example)

Binding

Prognosis or outlook findings.

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

0..*

Reference(Observation | Condition | DiagnosticReport | DocumentReference)

Element id

ClinicalImpression.supportingInfo

Short description

Unterstützende Informationen

Definition

Informationen, die die klinische Beurteilung unterstützen

Data type

Reference(Observation | Condition | DiagnosticReport | DocumentReference)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

note

0..*

Annotation

Element id

ClinicalImpression.note

Short description

Zusätzliche Anmerkungen

Definition

Kommentare zur Beurteilung, die anderswo nicht erfasst sind

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

Profile for clinical impressions in the context of rare diseases. This profile captures clinical assessments and suspected diagnoses based on phenotypic findings and symptoms.

Feldname	Kurzbeschreibung
ClinicalImpression.id
ClinicalImpression.meta
ClinicalImpression.identifier
ClinicalImpression.status	Status der klinischen Beurteilung
ClinicalImpression.code	Art der klinischen Beurteilung
ClinicalImpression.description	Zusammenfassung der klinischen Beurteilung
ClinicalImpression.subject	Patient, der beurteilt wird
ClinicalImpression.encounter
ClinicalImpression.effective[x]	Zeitpunkt der Beurteilung
ClinicalImpression.date	Wann die Beurteilung dokumentiert wurde
ClinicalImpression.problem	Relevante Probleme/Erkrankungen
ClinicalImpression.investigation	Eine oder mehrere Untersuchungsserien
ClinicalImpression.investigation.code	Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde
ClinicalImpression.summary	Zusammenfassung der klinischen Beurteilung
ClinicalImpression.finding	Klinische Befunde der Untersuchung
ClinicalImpression.supportingInfo	Unterstützende Informationen
ClinicalImpression.note	Zusätzliche Anmerkungen

<id value="mii-pr-seltene-clinical-impression" />
<url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression" />
<version value="2026.0.0-ballot" />
<name value="MII_PR_Seltene_ClinicalImpression" />
<title value="MII Profile SE Clinical Impression" />
<status value="draft" />
<publisher value="Medizininformatik Initiative" />
<contact>
<telecom>
<system value="url" />
<value value="https://www.medizininformatik-initiative.de" />
</telecom>
</contact>
<description value="Profile for clinical impressions in the context of rare diseases. This profile captures clinical assessments and suspected diagnoses based on phenotypic findings and symptoms." />
<fhirVersion value="4.0.1" />
<mapping>
<identity value="SE-LogicalModel" />
<uri value="https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/LogicalModel/Seltene" />
<name value="Mapping FHIR zu Seltene Erkrankungen Logical Model" />
</mapping>
<kind value="resource" />
<abstract value="false" />
<type value="ClinicalImpression" />
<baseDefinition value="http://hl7.org/fhir/StructureDefinition/ClinicalImpression" />
<derivation value="constraint" />
<differential>
<element id="ClinicalImpression">
<path value="ClinicalImpression" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik" />
<comment value="Anamnese und Diagnostik" />
</mapping>
</element>
<element id="ClinicalImpression.id">
<path value="ClinicalImpression.id" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.meta">
<path value="ClinicalImpression.meta" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.identifier">
<path value="ClinicalImpression.identifier" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.status">
<path value="ClinicalImpression.status" />
<short value="Status der klinischen Beurteilung" />
<mustSupport value="true" />
<binding>
<strength value="required" />
<valueSet value="http://hl7.org/fhir/ValueSet/clinicalimpression-status" />
</binding>
</element>
<element id="ClinicalImpression.code">
<path value="ClinicalImpression.code" />
<short value="Art der klinischen Beurteilung" />
<definition value="Kategorisiert die Art der klinischen Beurteilung, die erstellt wird" />
<mustSupport value="true" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Untersuchungsanlass" />
<comment value="Untersuchungsanlass" />
</mapping>
</element>
<element id="ClinicalImpression.description">
<path value="ClinicalImpression.description" />
<short value="Zusammenfassung der klinischen Beurteilung" />
<definition value="Eine Zusammenfassung der Beurteilung mit relevanter klinischer Begründung" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.subject">
<path value="ClinicalImpression.subject" />
<short value="Patient, der beurteilt wird" />
<definition value="Referenz auf den Patienten, für den diese klinische Beurteilung erstellt wird" />
<type>
<code value="Reference" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
</type>
<mustSupport value="true" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="Patient" />
<comment value="Patient/Indexpatient" />
</mapping>
</element>
<element id="ClinicalImpression.encounter">
<path value="ClinicalImpression.encounter" />
<mustSupport value="true" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Untersuchungsdatum" />
<comment value="Untersuchungskontakt" />
</mapping>
</element>
<element id="ClinicalImpression.effective[x]">
<path value="ClinicalImpression.effective[x]" />
<slicing>
<discriminator>
<type value="type" />
<path value="$this" />
</discriminator>
<ordered value="false" />
<rules value="open" />
</slicing>
<short value="Zeitpunkt der Beurteilung" />
<definition value="Der Zeitpunkt oder Zeitraum, über den die klinische Beurteilung gebildet wurde" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.effective[x]:effectiveDateTime">
<path value="ClinicalImpression.effective[x]" />
<sliceName value="effectiveDateTime" />
<min value="0" />
<max value="1" />
<type>
<code value="dateTime" />
</type>
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Untersuchungsdatum" />
<comment value="Untersuchungsdatum" />
</mapping>
</element>
<element id="ClinicalImpression.effective[x]:effectivePeriod">
<path value="ClinicalImpression.effective[x]" />
<sliceName value="effectivePeriod" />
<min value="0" />
<max value="1" />
<type>
<code value="Period" />
</type>
</element>
<element id="ClinicalImpression.effective[x]:effectivePeriod.start">
<path value="ClinicalImpression.effective[x].start" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Untersuchungsdatum" />
<comment value="Beginn der Untersuchung" />
</mapping>
</element>
<element id="ClinicalImpression.effective[x]:effectivePeriod.end">
<path value="ClinicalImpression.effective[x].end" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Untersuchungsdatum" />
<comment value="Ende der Untersuchung" />
</mapping>
</element>
<element id="ClinicalImpression.date">
<path value="ClinicalImpression.date" />
<short value="Wann die Beurteilung dokumentiert wurde" />
<definition value="Gibt an, wann die klinische Beurteilung dokumentiert wurde" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.problem">
<path value="ClinicalImpression.problem" />
<short value="Relevante Probleme/Erkrankungen" />
<definition value="Eine Liste der relevanten Probleme/Erkrankungen für diesen Patienten, die die klinische Beurteilung beeinflussen können" />
<mustSupport value="true" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.KlinischeDiagnose" />
<comment value="Klinische Diagnose/Verdacht" />
</mapping>
</element>
<element id="ClinicalImpression.investigation">
<path value="ClinicalImpression.investigation" />
<short value="Eine oder mehrere Untersuchungsserien" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.investigation.code">
<path value="ClinicalImpression.investigation.code" />
<short value="Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde" />
<mustSupport value="true" />
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.MethodeDiagnosestellung" />
<comment value="Methode der Diagnosestellung" />
</mapping>
</element>
<element id="ClinicalImpression.investigation.item">
<path value="ClinicalImpression.investigation.item" />
<short value="Unters" />
<type>
<code value="Reference" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Observation" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/RiskAssessment" />
</type>
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Phaenotypisierung" />
<comment value="Durchgeführte Untersuchungen" />
</mapping>
</element>
<element id="ClinicalImpression.summary">
<path value="ClinicalImpression.summary" />
<short value="Zusammenfassung der klinischen Beurteilung" />
<definition value="Eine Textzusammenfassung der Beurteilung mit hervorgehobenen wichtigsten Aspekten" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.finding">
<path value="ClinicalImpression.finding" />
<short value="Klinische Befunde der Untersuchung" />
<definition value="Klinische Befunde, die auf Basis der Untersuchungen festgestellt wurden" />
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.finding.itemCodeableConcept">
<path value="ClinicalImpression.finding.itemCodeableConcept" />
<short value="Klinischer Befund" />
<binding>
<strength value="extensible" />
<valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/ValueSet/mii-vs-seltene-hpo-phenotypic-observation-codes" />
</binding>
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Phaenotypisierung.HPOTerm" />
<comment value="HPO-Term des Symptoms" />
</mapping>
</element>
<element id="ClinicalImpression.finding.itemReference">
<path value="ClinicalImpression.finding.itemReference" />
<short value="Referenz auf klinischen Befund" />
<type>
<code value="Reference" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Condition" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Observation" />
</type>
<mapping>
<identity value="SE-LogicalModel" />
<map value="AnamneseUndDiagnostik.Phaenotypisierung" />
<comment value="Verweis auf Phänotypisierung" />
</mapping>
</element>
<element id="ClinicalImpression.finding.basis">
<path value="ClinicalImpression.finding.basis" />
<short value="Grundlage für den Befund" />
</element>
<element id="ClinicalImpression.supportingInfo">
<path value="ClinicalImpression.supportingInfo" />
<short value="Unterstützende Informationen" />
<definition value="Informationen, die die klinische Beurteilung unterstützen" />
<type>
<code value="Reference" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Observation" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Condition" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/DocumentReference" />
</type>
<mustSupport value="true" />
</element>
<element id="ClinicalImpression.note">
<path value="ClinicalImpression.note" />
<short value="Zusätzliche Anmerkungen" />
<definition value="Kommentare zur Beurteilung, die anderswo nicht erfasst sind" />
<mustSupport value="true" />
</element>
</differential>

</StructureDefinition>

{

"resourceType": "StructureDefinition",
"id": "mii-pr-seltene-clinical-impression",
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression",
"version": "2026.0.0-ballot",
"name": "MII_PR_Seltene_ClinicalImpression",
"title": "MII Profile SE Clinical Impression",
"status": "draft",
"publisher": "Medizininformatik Initiative",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "https://www.medizininformatik-initiative.de"
}
]
}
],
"description": "Profile for clinical impressions in the context of rare diseases. This profile captures clinical assessments and suspected diagnoses based on phenotypic findings and symptoms.",
"fhirVersion": "4.0.1",
"mapping": [
{
"identity": "SE-LogicalModel",
"name": "Mapping FHIR zu Seltene Erkrankungen Logical Model",
"uri": "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/LogicalModel/Seltene"
}
],
"kind": "resource",
"abstract": false,
"type": "ClinicalImpression",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "ClinicalImpression",
"path": "ClinicalImpression",
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik",
"comment": "Anamnese und Diagnostik"
}
]
},
{
"id": "ClinicalImpression.id",
"path": "ClinicalImpression.id",
"mustSupport": true
},
{
"id": "ClinicalImpression.meta",
"path": "ClinicalImpression.meta",
"mustSupport": true
},
{
"id": "ClinicalImpression.identifier",
"path": "ClinicalImpression.identifier",
"mustSupport": true
},
{
"id": "ClinicalImpression.status",
"path": "ClinicalImpression.status",
"short": "Status der klinischen Beurteilung",
"mustSupport": true,
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/clinicalimpression-status"
}
},
{
"id": "ClinicalImpression.code",
"path": "ClinicalImpression.code",
"short": "Art der klinischen Beurteilung",
"definition": "Kategorisiert die Art der klinischen Beurteilung, die erstellt wird",
"mustSupport": true,
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Untersuchungsanlass",
"comment": "Untersuchungsanlass"
}
]
},
{
"id": "ClinicalImpression.description",
"path": "ClinicalImpression.description",
"short": "Zusammenfassung der klinischen Beurteilung",
"definition": "Eine Zusammenfassung der Beurteilung mit relevanter klinischer Begründung",
"mustSupport": true
},
{
"id": "ClinicalImpression.subject",
"path": "ClinicalImpression.subject",
"short": "Patient, der beurteilt wird",
"definition": "Referenz auf den Patienten, für den diese klinische Beurteilung erstellt wird",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"mustSupport": true,
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "Patient",
"comment": "Patient/Indexpatient"
}
]
},
{
"id": "ClinicalImpression.encounter",
"path": "ClinicalImpression.encounter",
"mustSupport": true,
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Untersuchungsdatum",
"comment": "Untersuchungskontakt"
}
]
},
{
"id": "ClinicalImpression.effective[x]",
"path": "ClinicalImpression.effective[x]",
"slicing": {
"discriminator": [
{
"type": "type",
"path": "$this"
}
],
"ordered": false,
"rules": "open"
},
"short": "Zeitpunkt der Beurteilung",
"definition": "Der Zeitpunkt oder Zeitraum, über den die klinische Beurteilung gebildet wurde",
"mustSupport": true
},
{
"id": "ClinicalImpression.effective[x]:effectiveDateTime",
"path": "ClinicalImpression.effective[x]",
"sliceName": "effectiveDateTime",
"min": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Untersuchungsdatum",
"comment": "Untersuchungsdatum"
}
]
},
{
"id": "ClinicalImpression.effective[x]:effectivePeriod",
"path": "ClinicalImpression.effective[x]",
"sliceName": "effectivePeriod",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"id": "ClinicalImpression.effective[x]:effectivePeriod.start",
"path": "ClinicalImpression.effective[x].start",
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Untersuchungsdatum",
"comment": "Beginn der Untersuchung"
}
]
},
{
"id": "ClinicalImpression.effective[x]:effectivePeriod.end",
"path": "ClinicalImpression.effective[x].end",
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Untersuchungsdatum",
"comment": "Ende der Untersuchung"
}
]
},
{
"id": "ClinicalImpression.date",
"path": "ClinicalImpression.date",
"short": "Wann die Beurteilung dokumentiert wurde",
"definition": "Gibt an, wann die klinische Beurteilung dokumentiert wurde",
"mustSupport": true
},
{
"id": "ClinicalImpression.problem",
"path": "ClinicalImpression.problem",
"short": "Relevante Probleme/Erkrankungen",
"definition": "Eine Liste der relevanten Probleme/Erkrankungen für diesen Patienten, die die klinische Beurteilung beeinflussen können",
"mustSupport": true,
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.KlinischeDiagnose",
"comment": "Klinische Diagnose/Verdacht"
}
]
},
{
"id": "ClinicalImpression.investigation",
"path": "ClinicalImpression.investigation",
"short": "Eine oder mehrere Untersuchungsserien",
"mustSupport": true
},
{
"id": "ClinicalImpression.investigation.code",
"path": "ClinicalImpression.investigation.code",
"short": "Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde",
"mustSupport": true,
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.MethodeDiagnosestellung",
"comment": "Methode der Diagnosestellung"
}
]
},
{
"id": "ClinicalImpression.investigation.item",
"path": "ClinicalImpression.investigation.item",
"short": "Unters",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Observation",
"http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse",
"http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory",
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
"http://hl7.org/fhir/StructureDefinition/RiskAssessment"
]
}
],
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Phaenotypisierung",
"comment": "Durchgeführte Untersuchungen"
}
]
},
{
"id": "ClinicalImpression.summary",
"path": "ClinicalImpression.summary",
"short": "Zusammenfassung der klinischen Beurteilung",
"definition": "Eine Textzusammenfassung der Beurteilung mit hervorgehobenen wichtigsten Aspekten",
"mustSupport": true
},
{
"id": "ClinicalImpression.finding",
"path": "ClinicalImpression.finding",
"short": "Klinische Befunde der Untersuchung",
"definition": "Klinische Befunde, die auf Basis der Untersuchungen festgestellt wurden",
"mustSupport": true
},
{
"id": "ClinicalImpression.finding.itemCodeableConcept",
"path": "ClinicalImpression.finding.itemCodeableConcept",
"short": "Klinischer Befund",
"binding": {
"strength": "extensible",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/ValueSet/mii-vs-seltene-hpo-phenotypic-observation-codes"
},
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Phaenotypisierung.HPOTerm",
"comment": "HPO-Term des Symptoms"
}
]
},
{
"id": "ClinicalImpression.finding.itemReference",
"path": "ClinicalImpression.finding.itemReference",
"short": "Referenz auf klinischen Befund",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Condition",
"http://hl7.org/fhir/StructureDefinition/Observation"
]
}
],
"mapping": [
{
"identity": "SE-LogicalModel",
"map": "AnamneseUndDiagnostik.Phaenotypisierung",
"comment": "Verweis auf Phänotypisierung"
}
]
},
{
"id": "ClinicalImpression.finding.basis",
"path": "ClinicalImpression.finding.basis",
"short": "Grundlage für den Befund"
},
{
"id": "ClinicalImpression.supportingInfo",
"path": "ClinicalImpression.supportingInfo",
"short": "Unterstützende Informationen",
"definition": "Informationen, die die klinische Beurteilung unterstützen",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Observation",
"http://hl7.org/fhir/StructureDefinition/Condition",
"http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
"http://hl7.org/fhir/StructureDefinition/DocumentReference"
]
}
],
"mustSupport": true
},
{
"id": "ClinicalImpression.note",
"path": "ClinicalImpression.note",
"short": "Zusätzliche Anmerkungen",
"definition": "Kommentare zur Beurteilung, die anderswo nicht erfasst sind",
"mustSupport": true
}
]
}

}

MII Profile SE Clinical Impression

Suchparameter

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

Der Suchparameter _id MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?_id=1234

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-seltene/StructureDefinition/mii-pr-seltene-clinical-impression

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

Beispiele:

GET [base]/ClinicalImpression?status=completed

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

Beispiele:

GET [base]/ClinicalImpression?problem=Condition/example

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

Beispiele:

GET [base]/ClinicalImpression?encounter=Encounter/example

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

Beispiele:

GET [base]/ClinicalImpression?date=2024-02-08

Anwendungshinweise: Weitere Informationen zur Suche nach "date" finden sich in der FHIR-Basisspezifikation - Abschnitt "date".
Der Suchparameter "finding-ref" MUSS unterstützt werden:

Beispiele:

GET [base]/ClinicalImpression?finding-ref=Observation/example

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

Beispiele

Beispiel: Klinische Beurteilung bei Erstvorstellung

{

"resourceType": "ClinicalImpression",

"id": "clinical-impression-erstvorstellung",

"meta": {

"profile": [

"https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression"

]

"status": "completed",

"subject": {

"reference": "Patient/patient-sma-001"

"encounter": {

"reference": "Encounter/encounter-ambulant-001"

"effectiveDateTime": "2024-07-22",

"date": "2024-07-22",

"summary": "Neugeborenes mit V.a. SMA aus Neugeborenenscreening. Familienanamnese zeigt unklare Muskelerkrankung der Urgroßmutter. Troponin T bereits erhöht (92 ng/l).",

"problem": [

{

"reference": "Condition/condition-sma-suspected"

}

"finding": [

{

"reference": "Condition/condition-sma-clinical"

}

{

"reference": "Condition/condition-sma-genetic"

}

{

"coding": [

{

"code": "1363512008",
"system": "http://snomed.info/sct",
"display": "Troponin above reference range"

}

]

"reference": "Observation/observation-troponin-001"

}

"investigation": [

{

"code": {

"text": "Familienanamnese"

"item": [

{

"reference": "FamilyMemberHistory/family-history-001"

}

]

{

"code": {

"text": "Labordiagnostik"

"item": [

{

"reference": "Observation/observation-troponin-001"

}

]

}

"prognosisCodeableConcept": [

{

"coding": [

{

"code": "67334001",
"system": "http://snomed.info/sct",
"display": "Guarded prognosis"

}

]

}

"note": [

{

"text": "Klinische Untersuchung gemäß SMA-Diagnoseprotokoll. Blutentnahme für Genetik veranlasst."

{

"text": "Klinisches Bild vereinbar mit SMA Typ 1. Molekulargenetische Bestätigung ausstehend. Eltern über Therapieoptionen informiert."

}

]

}

Beispiel: Klinische Beurteilung bei Nachsorge

{

"resourceType": "ClinicalImpression",

"id": "clinical-impression-nachsorge",

"meta": {

"profile": [

"https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression"

]

"status": "completed",

"subject": {

"reference": "Patient/patient-sma-001"

"encounter": {

"reference": "Encounter/encounter-nachsorge-001"

"effectiveDateTime": "2024-08-12",

"date": "2024-08-12",

"previous": {

"reference": "ClinicalImpression/clinical-impression-erstvorstellung"

"summary": "Erste Nachsorge 14 Tage nach Gentherapie. Klinisch stabil. Troponin T weiter erhöht (106 ng/l), war jedoch bereits prätherapeutisch erhöht.",

"finding": [

{

"coding": [

{

"code": "1363512008",
"system": "http://snomed.info/sct",
"display": "Troponin above reference range"

}

]

"reference": "Observation/observation-troponin-004"

"basis": "Troponin-Verlauf: 22.07: 92 ng/l, 28.07: 58 ng/l, 01.08: 57 ng/l, 12.08: 106 ng/l"

{

"coding": [

{

"code": "166645004",
"system": "http://snomed.info/sct",
"display": "Alanine aminotransferase level within reference range"

}

]

"basis": "ALT normwertig"

{

"coding": [

{

"code": "166667003",
"system": "http://snomed.info/sct",
"display": "Aspartate aminotransferase/serum glutamic oxaloacetic transaminase level within reference range"

}

]

"basis": "AST normwertig"

{