Dieses Profil beschreibt eine Diagnose in der Medizininformatik-Initiative.
Canonical: https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose
Differential
Condition | Condition | Element IdCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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id | S Σ | 0..1 | System.String | There are no (further) constraints on this element Element IdCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. System.String |
meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element IdCondition.meta Metadata about the resource DefinitionThe 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.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdCondition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdCondition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. 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.
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source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element IdCondition.meta.source Identifies where the resource comes from DefinitionA 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. 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.
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profile | S Σ | 0..* | canonical | There are no (further) constraints on this element Element IdCondition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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.
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdCondition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. All Security Labels (extensible) Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.meta.tag Tags applied to this resource DefinitionTags 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. 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.
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdCondition.identifier External Ids for this condition DefinitionBusiness identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. 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.
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clinicalStatus | S Σ ?! | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.clinicalStatus active | recurrence | relapse | inactive | remission | resolved DefinitionThe clinical status of the condition. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. ConditionClinicalStatusCodes (required) Constraints
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verificationStatus | Σ ?! | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. ConditionVerificationStatus (required) Constraints
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category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. ConditionCategoryCodes (extensible) Constraints
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severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. Condition/DiagnosisSeverity (preferred) Constraints
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code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.code Identification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Condition/Problem/DiagnosisCodes (example) Constraints
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coding | S Σ | 1..* | Coding | Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Unordered, Open, by $this(Pattern) Constraints
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icd10-gm | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:icd10-gm Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
{ "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm" }
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extension | 0..* | Extension | Element IdCondition.code.coding:icd10-gm.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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Diagnosesicherheit | S | 0..1 | Extension(Coding) | Element IdCondition.code.coding:icd10-gm.extension:Diagnosesicherheit Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints
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Seitenlokalisation | S | 0..1 | Extension(Coding) | Element IdCondition.code.coding:icd10-gm.extension:Seitenlokalisation Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/seitenlokalisation Constraints
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AusrufezeichenCode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:AusrufezeichenCode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen Constraints
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ManifestationsCode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:ManifestationsCode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-manifestationscode Constraints
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Primaercode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:Primaercode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-primaercode Constraints
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | S Σ | 1..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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alpha-id | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:alpha-id Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. http://fhir.de/ValueSet/dimdi/alpha-id (required) Constraints
{ "system": "http://fhir.de/CodeSystem/dimdi/alpha-id" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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sct | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:sct Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. ValueSetSNOMED-Diagnose-Code (required) Constraints
{ "system": "http://snomed.info/sct" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:sct.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:sct.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:sct.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:sct.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:sct.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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orphanet | S Σ | 0..1 | Coding | Element IdCondition.code.coding:orphanet Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
{ "system": "http://www.orpha.net" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings.
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bodySite | S Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. SNOMEDCTBodyStructures (example) Constraints
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coding | S Σ | 1..* | Coding | Element IdCondition.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Unordered, Open, by system(Pattern) Constraints
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snomed-ct | S Σ | 1..1 | Coding | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
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system | S Σ | 1..1 | uri | Element IdCondition.bodySite.coding:snomed-ct.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.text Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings.
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subject | S Σ | 1..1 | MII-Reference(Patient| Group) | Element IdCondition.subject A reference from one resource to another Alternate namespatient DefinitionA reference from one resource to another. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
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onset[x] | S Σ | 0..1 | Element IdCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Closed, by $this(Type) Constraints
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onsetPeriod | S Σ | 0..1 | Period | Element IdCondition.onset[x]:onsetPeriod Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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start | S Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.onset[x]:onsetPeriod.start Starting time with inclusive boundary DefinitionThe start of the period. The boundary is inclusive. If the low element is missing, the meaning is that the low boundary is not known.
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extension | 0..* | Extension | Element IdCondition.onset[x]:onsetPeriod.start.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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lebensphase-von | S | 0..1 | Extension(CodeableConcept) | Element IdCondition.onset[x]:onsetPeriod.start.extension:lebensphase-von Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Stage_Life Constraints
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end | S Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.onset[x]:onsetPeriod.end End time with inclusive boundary, if not ongoing DefinitionThe 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. 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.
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extension | 0..* | Extension | Element IdCondition.onset[x]:onsetPeriod.end.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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lebensphase-bis | S | 0..1 | Extension(CodeableConcept) | Element IdCondition.onset[x]:onsetPeriod.end.extension:lebensphase-bis Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Stage_Life Constraints
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onsetDateTime | S Σ | 0..1 | dateTime | Element IdCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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abatement[x] | 0..1 | There are no (further) constraints on this element Element IdCondition.abatement[x] When in resolution/remission DefinitionThe date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
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abatementDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
abatementAge | Age | There are no (further) constraints on this element Data Type | ||
abatementPeriod | Period | There are no (further) constraints on this element Data Type | ||
abatementRange | Range | There are no (further) constraints on this element Data Type | ||
abatementString | string | There are no (further) constraints on this element Data Type | ||
recordedDate | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element IdCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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recorder | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | There are no (further) constraints on this element Element IdCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
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asserter | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | There are no (further) constraints on this element Element IdCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
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stage | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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summary | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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assessment | 0..* | Reference(ClinicalImpression| DiagnosticReport| Observation) | There are no (further) constraints on this element Element IdCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ClinicalImpression| DiagnosticReport| Observation) Constraints
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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evidence | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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code | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. ManifestationAndSymptomCodes (example) Constraints
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detail | Σ | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | S | 0..* | Annotation | There are no (further) constraints on this element Element IdCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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FHIR-Element | Erklärung |
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Condition.id | Must-support, jedoch optional |
Condtion.meta | Must-support, jedoch optional |
Condtion.clinicalStatus | Keine Einschränkungen, Kompletter Diagnose-Workflow wird unterstützt. Das Element ist optional, da es nicht routinemäßig erfasst wird. Zudem wird der Status bei der Entlassung meist nicht erfasst. |
Condtion.code | Min. 1 kodierte Diagnose muss enthalten sein. System frei aus Alpha-ID, SNOMED CT, Orpahanet und ICD-10 GM wählbar. |
Condtion.code.coding:icd10-gm.extension | Innerhalb der Extensions "AusrufezeichenCode", "ManifestationsCode" und "Primaercode", sollten die jeweiligen Code-Bestandteile ohne jeweilige Sonderzeichen (z.B. "!", "+" oder "*") kodiert werden. |
Condtion.bodySite | Falls dieses optionale Element verwendet wird, muss die Körperstelle min. mit einem SNOMED-CT Code kodiert werden. Hierbei ist nicht die Lateralität anzugeben, diese sollte per Condition.code.coding:icd10-gm.extenison:Seitenlokalisation angegeben werden. Feld dient dazu zusätzliche Angaben (über den Code hinausgehend) zur Manifestation zu dokumentieren. |
Condtion.subject | Die Referenz zum Modul Person ist stets gegeben. |
Condition.encounter | Es ist zu beachten, dass in den meisten Fällen dieses Feld nicht zur Verknüpfung des Falls und der Diagnose verwendet werden sollte. Dieses Element dient zur Verknüpfung der Diagnose mit dem Fall / Kontakt in dem die Diagnose festgestellt wird (immer ein Kontakt mit einer konkreten Versorgungsstelle!). Generell sollte die Verknüpfung über Encounter.diagnosis erfolgen. |
Condtion.onset[x] | In Anlehnung an die IPS als Period oder dateTime kodierbar. Lebensphasen können zusätzlich angegeben falls genaue Zeitpunkte nicht bekannt sind. |
Condtion.recordedDate | Dient der zeitlichen Einordnung der Diagnose (Anstelle der Abfragen auf des initialen Abteilungsfall der Feststellung der Diagnose) |
Condtion.note | Zusätzliche Erläuterung der Diagnose |
FHIR-Element | Erklärung |
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Encounter.period.start / Diagnose.encounter | Es ist zu beachten, dass die Abbildung des logischen Datenelementes "Fesstellungsdatum" nicht auf die Condition-Ressource sondern auf die Encounter-Ressource erfolgt. Somit SOLLTE die Verknüpfung der Diagnose immer auf einen Versorgungsstellen-Kontakt erfolgen (Siehe Modul Fall). |
FHIR Element | Logischer Datensatz |
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Condition.code:icd-10gm | Diagnose.ICD10GMDiagnoseKodiert |
Condition.code:icd-10gm.coding.code | Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:icd-10gm.coding:extension:Primaercode | Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode |
Condition.code:icd-10gm.coding:extension:ManifestationsCode | Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode |
Condition.code:icd-10gm.coding:extension:AusrufezeichenCode | Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode |
Condition.code:icd-10gm.coding:extension:Diagnosesicherheit | Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit |
Condition.code:icd-10gm.coding:extension:Seitenlokalisation | Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation |
Condition.code:alpha-id | Diagnose.ALPHAIDDiagnoseKodiert |
Condition.code:alpha-id (coding.system, coding.value) | Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:orphanet | Diagnose.ORPHANETDiagnoseKodiert |
Condition.code:orphanet (coding.system, coding.value) | Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:sct | Diagnose.SNOMEDDiagnoseKodiert |
Condition.code:sct (coding.system, coding.value) | Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code | Diagnose.WeitereKodiersysteme |
Condition.code (coding.system, coding.value) | Diagnose.WeitereKodesysteme.VollständigerDiagnosecode |
Condition.bodySite | Diagnose.Körperstelle |
Condition.code.text | Diagnose.Freitextbeschreibung |
Condition.note | Diagnose.Diagnoseerläuterung |
Condition.recordedDate | Diagnose.Dokumentationsdatum |
Condition.clinicalStatus | Diagnose.KlinscherStatus |
Condition.onset[x] | Diagnose.KlinischRelevanterZeitraum |
Condition.onsetPeriod | Diagnose.KlinischRelevanterZeitraum.Zeitraum |
Condition.onsetPeriod.start | Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am |
Condition.onsetPeriod.end | Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis |
n.A. | Diagnose.KlinischRelevanterZeitraum.Lebensphase |
Condition.onsetPeriod.start.extension:lebensphase-start | Diagnose.KlinischRelevanterZeitraum.Lebensphase.von |
Condition.onsetPeriod.end.extension:lebensphase-ende | Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis |
FHIR Element | Logischer Datensatz |
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Encounter.period.start | Diagnose.Feststellungsdatum |
Invarianten | Beschreibung | Expression |
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sct-icd-1 | Entweder wird die Diagnose mit ICD oder SNOMED-CT kodiert | coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/dimdi/ops').exists() |
icd-1 | Bei Angabe eines Codes in der Haupt-Kreuz-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! | extension('https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/icd-10-gm-primaercode').empty() or code.contains($this.extension('https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/icd-10-gm-primaercode').value.code) |
icd-2 | Bei Angabe eines Codes in der Stern-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! | extension('https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/icd-10-gm-manifestation').empty() or code.contains($this.extension('https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/icd-10-gm-manifestation').value.code) |
icd-3 | Bei Angabe eines Codes in der Ausrufezeichen-Extension, muss dieser auch Bestandteil des postkoordinierten ICD-Codes sein! | extension('http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen').empty() or code.contains($this.extension('http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen').value.code) |
icd-8 | Bei Angabe eines Codes in der Seitenlokalisations-Extension, muss dieser auch Bestandteil des ICD-Codes sein! | extension('http://fhir.de/StructureDefinition/seitenlokalisation').empty() or code.contains($this.extension('http://fhir.de/StructureDefinition/seitenlokalisation').value.code) |
Snapshot
Condition | Condition | Element IdCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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id | S Σ | 0..1 | System.String | There are no (further) constraints on this element Element IdCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. System.String |
meta | S Σ | 0..1 | Meta | There are no (further) constraints on this element Element IdCondition.meta Metadata about the resource DefinitionThe 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.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdCondition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdCondition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. 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.
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source | S Σ | 0..1 | uri | There are no (further) constraints on this element Element IdCondition.meta.source Identifies where the resource comes from DefinitionA 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. 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.
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profile | S Σ | 0..* | canonical | There are no (further) constraints on this element Element IdCondition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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.
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdCondition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. All Security Labels (extensible) Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.meta.tag Tags applied to this resource DefinitionTags 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. 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.
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdCondition.identifier External Ids for this condition DefinitionBusiness identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. 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.
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clinicalStatus | S Σ ?! | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.clinicalStatus active | recurrence | relapse | inactive | remission | resolved DefinitionThe clinical status of the condition. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. ConditionClinicalStatusCodes (required) Constraints
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verificationStatus | Σ ?! | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. ConditionVerificationStatus (required) Constraints
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category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. ConditionCategoryCodes (extensible) Constraints
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severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. Condition/DiagnosisSeverity (preferred) Constraints
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code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.code Identification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Condition/Problem/DiagnosisCodes (example) Constraints
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coding | S Σ | 1..* | Coding | Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Unordered, Open, by $this(Pattern) Constraints
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icd10-gm | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:icd10-gm Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
{ "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm" }
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extension | 0..* | Extension | Element IdCondition.code.coding:icd10-gm.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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Diagnosesicherheit | S | 0..1 | Extension(Coding) | Element IdCondition.code.coding:icd10-gm.extension:Diagnosesicherheit Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints
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Seitenlokalisation | S | 0..1 | Extension(Coding) | Element IdCondition.code.coding:icd10-gm.extension:Seitenlokalisation Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/seitenlokalisation Constraints
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AusrufezeichenCode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:AusrufezeichenCode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen Constraints
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ManifestationsCode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:ManifestationsCode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-manifestationscode Constraints
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Primaercode | S | 0..* | Extension(Coding-Profil für ICD-10-GM) | Element IdCondition.code.coding:icd10-gm.extension:Primaercode Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. Extension(Coding-Profil für ICD-10-GM) Extension URLhttp://fhir.de/StructureDefinition/icd-10-gm-primaercode Constraints
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | S Σ | 1..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:icd10-gm.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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alpha-id | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:alpha-id Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. http://fhir.de/ValueSet/dimdi/alpha-id (required) Constraints
{ "system": "http://fhir.de/CodeSystem/dimdi/alpha-id" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:alpha-id.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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sct | S Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:sct Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. ValueSetSNOMED-Diagnose-Code (required) Constraints
{ "system": "http://snomed.info/sct" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:sct.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:sct.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:sct.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:sct.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:sct.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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orphanet | S Σ | 0..1 | Coding | Element IdCondition.code.coding:orphanet Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
{ "system": "http://www.orpha.net" }
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings.
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bodySite | S Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. SNOMEDCTBodyStructures (example) Constraints
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coding | S Σ | 1..* | Coding | Element IdCondition.bodySite.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Unordered, Open, by system(Pattern) Constraints
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snomed-ct | S Σ | 1..1 | Coding | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
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system | S Σ | 1..1 | uri | Element IdCondition.bodySite.coding:snomed-ct.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.bodySite.coding:snomed-ct.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.bodySite.text Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings.
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subject | S Σ | 1..1 | MII-Reference(Patient| Group) | Element IdCondition.subject A reference from one resource to another Alternate namespatient DefinitionA reference from one resource to another. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
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onset[x] | S Σ | 0..1 | Element IdCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Closed, by $this(Type) Constraints
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onsetPeriod | S Σ | 0..1 | Period | Element IdCondition.onset[x]:onsetPeriod Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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start | S Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.onset[x]:onsetPeriod.start Starting time with inclusive boundary DefinitionThe start of the period. The boundary is inclusive. If the low element is missing, the meaning is that the low boundary is not known.
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extension | 0..* | Extension | Element IdCondition.onset[x]:onsetPeriod.start.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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lebensphase-von | S | 0..1 | Extension(CodeableConcept) | Element IdCondition.onset[x]:onsetPeriod.start.extension:lebensphase-von Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Stage_Life Constraints
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end | S Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.onset[x]:onsetPeriod.end End time with inclusive boundary, if not ongoing DefinitionThe 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. 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.
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extension | 0..* | Extension | Element IdCondition.onset[x]:onsetPeriod.end.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Constraints
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lebensphase-bis | S | 0..1 | Extension(CodeableConcept) | Element IdCondition.onset[x]:onsetPeriod.end.extension:lebensphase-bis Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Stage_Life Constraints
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onsetDateTime | S Σ | 0..1 | dateTime | Element IdCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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abatement[x] | 0..1 | There are no (further) constraints on this element Element IdCondition.abatement[x] When in resolution/remission DefinitionThe date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
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abatementDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
abatementAge | Age | There are no (further) constraints on this element Data Type | ||
abatementPeriod | Period | There are no (further) constraints on this element Data Type | ||
abatementRange | Range | There are no (further) constraints on this element Data Type | ||
abatementString | string | There are no (further) constraints on this element Data Type | ||
recordedDate | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element IdCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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recorder | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | There are no (further) constraints on this element Element IdCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
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asserter | Σ | 0..1 | Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) | There are no (further) constraints on this element Element IdCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner| PractitionerRole| Patient| RelatedPerson) Constraints
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stage | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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summary | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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assessment | 0..* | Reference(ClinicalImpression| DiagnosticReport| Observation) | There are no (further) constraints on this element Element IdCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ClinicalImpression| DiagnosticReport| Observation) Constraints
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.
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evidence | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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code | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. ManifestationAndSymptomCodes (example) Constraints
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detail | Σ | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | S | 0..* | Annotation | There are no (further) constraints on this element Element IdCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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Beispiele
Beispiel ICD-10-GM & SNOMED CT:
{ "resourceType": "Condition", "id": "ExampleCondition", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose" ] }, "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "code": { "coding": [ { "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version": "2020", "code": "S50.0", "display": "Prellung des Ellenbogens" }, { "system": "http://snomed.info/sct", "code": "91613004", "display": "Contusion of elbow (disorder)" } ], "text": "Prellung des linken Ellenbogens" }, "subject": { "reference": "Patient/12345" }, "onsetPeriod": { "start": "2020-02-26T12:00:00+01:00", "end": "2020-03-05T13:00:00+01:00" }, "recordedDate": "2020-02-26T12:00:00+01:00" }
Beispiel (ICD-10-GM Diagnose mit Kreuz-Stern-System und Zusatzkennzeichen):
{ "resourceType": "Condition", "id": "ExampleConditionDuplicate2", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose" ] }, "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "verificationStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status", "code": "confirmed" } ] }, "code": { "coding": [ { "extension": [ { "url": "http://fhir.de/StructureDefinition/icd-10-gm-primaercode", "valueCoding": { "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version": "2020", "code": "A54.4" } }, { "url": "http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode", "valueCoding": { "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version": "2020", "code": "M73.04" } }, { "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit", "valueCoding": { "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT", "code": "G" } }, { "url": "http://fhir.de/StructureDefinition/seitenlokalisation", "valueCoding": { "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION", "code": "L", "display": "links" } } ], "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version": "2020", "code": "A54.4† M73.04*", "display": "Bursitis gonorrhoica" } ] }, "subject": { "reference": "Patient/12345" }, "onsetPeriod": { "start": "2019-09-26T12:45:00+01:00", "end": "2020-03-25T13:00:00+01:00" }, "recordedDate": "2020-01-05T12:53:00+01:00" }
Beispiel (Alpha-ID und Orpha-Kennnummer):
{ "resourceType": "Condition", "id": "ExampleConditionDuplicate3", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose" ] }, "clinicalStatus": { "coding": [ { "system": "http://terminology.hl7.org/CodeSystem/condition-clinical", "code": "active" } ] }, "code": { "coding": [ { "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm", "version": "2020", "code": "H83.8", "display": "Sonstige näher bezeichnete Krankheiten des Innenohres" }, { "system": "http://fhir.de/ValueSet/dimdi/alpha-id", "code": "I125918" }, { "system": "http://www.orpha.net", "code": "420402", "display": "Bogengangsdehiszenz-Syndrom" } ] }, "subject": { "reference": "Patient/12345" }, "onsetPeriod": { "start": "2020-02-13T16:56:00+01:00" }, "recordedDate": "2020-04-26T12:00:00+01:00" }
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