MII IG Diagnose DE v2024

Datensätze inkl. Beschreibungen

Die offizielle und abgenommene Version des Informationsmodells für das Modul PERSON ist nachfolgend als FHIR Logical Model abgebildet:

Diagnose			Diagnose	Element id Diagnose Short description Das Basismodul Diagnosen enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc. Definition Logische Repräsentation des Basismoduls Diagnose Data type Diagnose Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
ICD10GMDiagnoseKodiert		0..1	BackboneElement	Element id Diagnose.ICD10GMDiagnoseKodiert Short description Im Bereich der administrativen und statistischen Auswertung wird die Diagnose mit Hilfe von Codiersystemen verschlüsselt. So wird z.B. bei der Abrechnung nach §301 und §295 SGB V die Codierung von Diagnosen mittels ICD-10-GM gesetzlich vorgeschrieben. Weitere Codiersysteme sind z.B. die Alpha-ID oder SNOMED CT. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein. Definition Im Bereich der administrativen und statistischen Auswertung wird die Diagnose mit Hilfe von Codiersystemen verschlüsselt. So wird z.B. bei der Abrechnung nach §301 und §295 SGB V die Codierung von Diagnosen mittels ICD-10-GM gesetzlich vorgeschrieben. Weitere Codiersysteme sind z.B. die Alpha-ID oder SNOMED CT. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm')
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ICD10GMDiagnoseKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ICD10GMDiagnoseKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ICD10GMDiagnoseKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Diagnosecode		1..1	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Diagnosecode Short description Diagnosecode ICD-10-GM Definition Code ohne Zusatzkennzeichen Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').code
Mehrfachkodierungskennzeichen		0..1	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Mehrfachkodierungskennzeichen Short description Mehrfachkodierungskennzeichen Definition Mehrfachkodierungskennzeichen Kreuz-Stern-System und Ausrufezeichen ("", "†", "!"). Comments* Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').extension('http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen').valueCoding.code
Diagnosesicherheit		0..1	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit Short description Zusatzkennzeichen für die Diagnosensicherhe Definition Die Diagnosensicherheit, d.h. wie sicher die Diagnose im Einzelfall zu werten ist, kann unterschiedlich angegeben werden. Für Abrechnungszwecke in der ambulanten Versorgung muss obligatorisch ein Zusatzkennzeichen für die Diagnosensicherheit (A, G, V oder Z) angegeben werden, d. h. die Angabe ist obligatorisch. In der stationären Versorgung sind diese Zusatzkennzeichen für die Angabe der Diagnosensicherheit für Abrechnungszwecke dagegen nicht zulässig. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').extension('http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit').valueCoding.code
Seitenlokalisation		0..1	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation Short description Zusatzkennzeichen Seite einer Erkrankung Definition Zusatzkennzeichen der ICD-10 für die Seitigkeit einer Diagnose (R, L, B) Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').extension('http://fhir.de/StructureDefinition/seitenlokalisation').valueCoding.code
ALPHAIDKodiert		0..1	BackboneElement	Element id Diagnose.ALPHAIDKodiert Short description Kodierung einer Diagnose mit Alpha-ID Definition Kodierung einer Diagnose mit Alpha-ID Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/alpha-id')
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ALPHAIDKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ALPHAIDKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ALPHAIDKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Diagnosecode		1..1	code	Element id Diagnose.ALPHAIDKodiert.Diagnosecode Short description Alpha-ID-Code Definition Alpha-ID-Code Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/alpha-id').code
ORPHANETDiagnoseKodiert		0..1	BackboneElement	Element id Diagnose.ORPHANETDiagnoseKodiert Short description Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. Definition Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://www.orpha.net')
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ORPHANETDiagnoseKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ORPHANETDiagnoseKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.ORPHANETDiagnoseKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Diagnosecode		1..1	code	Element id Diagnose.ORPHANETDiagnoseKodiert.Diagnosecode Short description Orpha-Kennnummer Definition Orpha-Kennnummer Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://www.orpha.net').code
SNOMEDDiagnoseKodiert		0..1	BackboneElement	Element id Diagnose.SNOMEDDiagnoseKodiert Short description Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT Definition Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://snomed.info/sct')
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.SNOMEDDiagnoseKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.SNOMEDDiagnoseKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.SNOMEDDiagnoseKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Diagnosecode		1..1	code	Element id Diagnose.SNOMEDDiagnoseKodiert.Diagnosecode Short description SNOMED-CT Code Definition SNOMED-CT Code Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.where(system='http://snomed.info/sct').code
WeitereKodiersysteme		0..*	BackboneElement	Element id Diagnose.WeitereKodiersysteme Short description Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich. Definition Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.WeitereKodiersysteme.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.WeitereKodiersysteme.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.WeitereKodiersysteme.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Diagnosecode		1..1	code	Element id Diagnose.WeitereKodiersysteme.Diagnosecode Short description Code aus weiterem Kodiersystem Definition Angabe des Codes aus weiterem Kodiersystem Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.coding.code
Koerperstelle		0..*	code	Element id Diagnose.Koerperstelle Short description Körperstelle Definition Über die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (Topografische Informatiomn) Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.bodySite
Freitextbeschreibung		0..1	string	Element id Diagnose.Freitextbeschreibung Short description Diagnose im Klartext Definition Diagnose im Klartext. Im Bereich der medizinischen Dokumentation sollte die Textbeschreibung obligatorisch sein. Bei der sekundären Übernahme einer kodierten Diagonse aus der Primärdokumentation kann eine Freitextbeschreibung fehlen. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.code.text
Diagnoseerlaeuterung		0..*	string	Element id Diagnose.Diagnoseerlaeuterung Short description Diagnoseerläuterung Definition Damit soll dem Arzt die Möglichkeit gegeben werden, umfangreichere Angaben zusätzlich zu einer Diagnose abzufassen. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.note
KlinischerStatus		0..1	code	Element id Diagnose.KlinischerStatus Short description Klinischer Status Definition aktiv, Rezidiv, Rückfall, inaktiv, Remission, geheilt Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.clinicalStatus
KlinischRelevanterZeitraum		0..1	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum Short description Klinisch relevanter Zeitraum Definition Hier kann der Klinisch Relevante Zeitraum beziehungsweise die Lebensphase einer Erkrankung angegeben werden. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onset[x]
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Zeitraum		0..1	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum Short description klinisch relevanter Zeitraum Definition Der Zeitraum wird durch zwei Datumsangaben beschrieben, das heißt, von wann bis wann ein Patient an der diagnostizierten Krankheit litt. Über den Zeitraum kann auch ausgedrückt werden, seit wann ein Patient an einer Krankheit leidet, indem nur das Startdatum des Zeitraums angegeben wird. Das Startdatum des Zeitraums kann abweichen von dem Diagnosedatum. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onsetPeriod
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
von		0..1	dateTime	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.von Short description Startdatum Definition Startdatum Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onsetPeriod.start
bis		0..1	dateTime	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis Short description Enddatum Definition Enddatum Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onsetPeriod.end
Lebensphase		0..*	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase Short description Lebensphase Definition Lebensphase, in der die Erkrankung aufgetreten ist Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
von		0..1	code	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.von Short description In welcher Lebensphase die Krankheit began Definition In welcher Lebensphase die Krankheit began Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onsetPeriod.start.extension('http://fhir.de/StructureDefinition/lebensphase').valueCodeableConcept
bis		0..1	code	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis Short description In welcher Lebensphase die Krankheit endete Definition In welcher Lebensphase die Krankheit endete Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.onsetPeriod.end.extension('http://fhir.de/StructureDefinition/lebensphase').valueCodeableConcept
Feststellungsdatum		0..1	date	Element id Diagnose.Feststellungsdatum Short description Feststellungsdatum / Diagnosedatum Definition Das Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt festgestellt wurde. Dies wird im Folgenden mit Diagnosedatum bezeichnet. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.extension('http://hl7.org/fhir/StructureDefinition/condition-assertedDate').valueDateTime
Dokumentationsdatum		1..1	date	Element id Diagnose.Dokumentationsdatum Short description Dokumentationsdatum Definition Das Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt dokumentiert wurde. Hinweis: Wenn zwischen Feststellung der Diagnose und Dokumentationsdatum nicht unterschieden werden muss, ist das Datum der Feststellung der Diagnose (Diagnosedatum) anzugeben. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Condition.recordedDate

Es ist zu beachten, dass das Logical Model rein auf die Abbildung der Datenelemente und deren Beschreibung abzielt. Verwendete Datentypen und Kardinalitäten sind nicht als verpflichtend anzusehen. Dies wird abschließend durch die FHIR-Profile festgelegt. Für jedes Element innerhalb des Logical Models existiert ein 1:1 Mapping auf ein Element einer konkreten FHIR Ressource

Logischer_Datensatz	Beschreibung
Diagnose	Das Basismodul Diagnosen enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc.
Diagnose.ICD10GMDiagnoseKodiert	Im Bereich der administrativen und statistischen Auswertung wird die Diagnose mit Hilfe von Codiersystemen verschlüsselt. So wird z.B. bei der Abrechnung nach §301 und §295 SGB V die Codierung von Diagnosen mittels ICD-10-GM gesetzlich vorgeschrieben. Weitere Codiersysteme sind z.B. die Alpha-ID oder SNOMED CT. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein.
Diagnose.ICD10GMDiagnoseKodiert.Diagnosecode	Diagnosecode ICD-10-GM
Diagnose.ICD10GMDiagnoseKodiert.Mehrfachkodierungskennzeichen	Mehrfachkodierungskennzeichen
Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit	Zusatzkennzeichen für die Diagnosensicherhe
Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation	Zusatzkennzeichen Seite einer Erkrankung
Diagnose.ALPHAIDKodiert	Kodierung einer Diagnose mit Alpha-ID
Diagnose.ALPHAIDKodiert.Diagnosecode	Alpha-ID-Code
Diagnose.ORPHANETDiagnoseKodiert	Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich.
Diagnose.ORPHANETDiagnoseKodiert.Diagnosecode	Orpha-Kennnummer
Diagnose.SNOMEDDiagnoseKodiert	Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT
Diagnose.SNOMEDDiagnoseKodiert.Diagnosecode	SNOMED-CT Code
Diagnose.WeitereKodiersysteme	Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich.
Diagnose.WeitereKodiersysteme.Diagnosecode	Code aus weiterem Kodiersystem
Diagnose.Koerperstelle	Körperstelle
Diagnose.Freitextbeschreibung	Diagnose im Klartext
Diagnose.Diagnoseerlaeuterung	Diagnoseerläuterung
Diagnose.KlinischerStatus	Klinischer Status
Diagnose.KlinischRelevanterZeitraum	Klinisch relevanter Zeitraum
Diagnose.KlinischRelevanterZeitraum.Zeitraum	klinisch relevanter Zeitraum
Diagnose.KlinischRelevanterZeitraum.Zeitraum.von	Startdatum
Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis	Enddatum
Diagnose.KlinischRelevanterZeitraum.Lebensphase	Lebensphase
Diagnose.KlinischRelevanterZeitraum.Lebensphase.von	In welcher Lebensphase die Krankheit began
Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis	In welcher Lebensphase die Krankheit endete
Diagnose.Feststellungsdatum	Feststellungsdatum / Diagnosedatum
Diagnose.Dokumentationsdatum	Dokumentationsdatum