MII-Initiative

MII IG Diagnose DE v2024

Condition


Beschreibung

Dieses Profil beschreibt eine Diagnose in der Medizininformatik-Initiative.

Mehrfachkodierung und Condition-Ressourcen

Bei der Kombination von ICD-10-Codes mit dem Kreuz-Stern-System wird für jeden ICD-10-Code (Ätiologie, Manifestation, Zusatzinformation) eine Condition-Ressource instanziiert. Die Condition-Ressourcen der Sekundärdiagnosen (Manifestation, Zusatzinformation) nutzen die Extension Condition Related, um auf die Primärdiagnose (Ätiologie) zu referenzieren. Zusätzlich zu kombinierten ICD-10-Codes gemappte Alpha-IDs oder Orpha-Codes, werden nur in der Condition-Ressource der Primärdiagnose angegeben. Bei abweichenden Diagnosesicherheiten zwischen Primär- und Sekundärdiagnose MUSS sichergestellt werden, dass die Diagnosesicherheit der Primärcondition auf die assoziierte Alpha-ID zutrifft. Das Vorgehen wird anhand der Beispielressourcen exemplarisch für Alpha-ID I97525 und ICD-10-GM A54.4+ M73.09* dargestellt.

Gegebenenfalls vorhandene Mehrfachkodierungskennzeichen (*, , !) werden von den jeweiligen ICD-10-Codes abgetrennt und in die Extension 'Mehrfachkodierungs-Kennzeichen' gesetzt. Das Element Condition.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/icd-10-gm').code, in dem der ICD-10-GM-Code abgebildet wird, SOLLTE NICHT ein Mehrfachkodierungskennzeichen oder Zusatzkennzeichen (z.B. Seitenlokalisation oder Diagnosesicherheit) enthalten. Siehe Beispielressourcen.

NameStatusVersionCanonicalBasis
MII_PR_Diagnose_Conditionactive2024.0.0https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnosehttp://hl7.org/fhir/StructureDefinition/Condition

Inhalt

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
FeststellungsdatumS I0..1Extension(dateTime)
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
verificationStatusΣ ?! I0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ0..1uri
versionΣ0..1string
codeΣ0..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
Mehrfachcodierungs-KennzeichenI0..1Extension(Coding)
SeitenlokalisationI0..1Extension(Coding)
DiagnosesicherheitI0..1Extension(Coding)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ I1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionS Σ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionS Σ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionS Σ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
id0..1string
extensionI0..*Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
value0..1System.DateTime
id0..1string
id0..1string
extensionI0..*Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
value0..1System.DateTime
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation

Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative

FeldnameKurzbeschreibung
Condition.id
Condition.meta
Condition.meta.source
Condition.meta.profile
Condition.extension:ReferenzPrimaerdiagnose
Condition.extension:Feststellungsdatum
Condition.clinicalStatus
Condition.code
Condition.code.coding
Condition.code.coding:icd10-gm
Condition.code.coding:icd10-gm.system
Condition.code.coding:icd10-gm.version
Condition.code.coding:icd10-gm.code
Condition.code.coding:alpha-id
Condition.code.coding:alpha-id.system
Condition.code.coding:alpha-id.code
Condition.code.coding:sct
Condition.code.coding:sct.system
Condition.code.coding:sct.version
Condition.code.coding:sct.code
Condition.code.coding:orphanet
Condition.code.coding:orphanet.system
Condition.code.coding:orphanet.code
Condition.code.coding:icd-o-3ICD-O-3 Morphologie
Condition.code.coding:icd-o-3.system
Condition.code.coding:icd-o-3.version
Condition.code.coding:icd-o-3.code
Condition.bodySite
Condition.bodySite.coding
Condition.bodySite.coding:snomed-ct
Condition.bodySite.coding:snomed-ct.system
Condition.bodySite.coding:snomed-ct.version
Condition.bodySite.coding:snomed-ct.code
Condition.bodySite.coding:icd-o-3ICD-O-3 Topographie
Condition.bodySite.coding:icd-o-3.system
Condition.bodySite.coding:icd-o-3.code
Condition.subject
Condition.encounter
Condition.onset[x]
Condition.onset[x]:onsetPeriod
Condition.onset[x]:onsetPeriod.start
Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von
Condition.onset[x]:onsetPeriod.end
Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis
Condition.onset[x]:onsetDateTime
Condition.recordedDate
Condition.note
<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-diagnose-condition" />
    <url value="https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose" />
    <version value="2024.0.0" />
    <name value="MII_PR_Diagnose_Condition" />
    <title value="MII PR Diagnose Condition" />
    <status value="active" />
    <date value="2024-02-08" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative" />
    <fhirVersion value="4.0.1" />
    <mapping>
        <identity value="LogicalModel" />
        <name value="FHIR-Profil zu LogicalModel Mapping" />
    </mapping>
    <kind value="resource" />
    <abstract value="false" />
    <type value="Condition" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Condition" />
    <derivation value="constraint" />
    <differential>
        <element id="Condition.id">
            <path value="Condition.id" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.meta">
            <path value="Condition.meta" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.meta.source">
            <path value="Condition.meta.source" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.meta.profile">
            <path value="Condition.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.extension:ReferenzPrimaerdiagnose">
            <path value="Condition.extension" />
            <sliceName value="ReferenzPrimaerdiagnose" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="http://hl7.org/fhir/StructureDefinition/condition-related" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.extension:Feststellungsdatum">
            <path value="Condition.extension" />
            <sliceName value="Feststellungsdatum" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="http://hl7.org/fhir/StructureDefinition/condition-assertedDate" />
            </type>
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="Feststellungsdatum" />
            </mapping>
        </element>
        <element id="Condition.clinicalStatus">
            <path value="Condition.clinicalStatus" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischerStatus" />
            </mapping>
        </element>
        <element id="Condition.code">
            <path value="Condition.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding">
            <path value="Condition.code.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <min value="1" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="WeitereKodiersysteme" />
            </mapping>
        </element>
        <element id="Condition.code.coding.code">
            <path value="Condition.code.coding.code" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="WeitereKodiersysteme.Diagnosecode" />
            </mapping>
        </element>
        <element id="Condition.code.coding:icd10-gm">
            <path value="Condition.code.coding" />
            <sliceName value="icd10-gm" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Coding" />
                <profile value="http://fhir.de/StructureDefinition/CodingICD10GM" />
            </type>
            <patternCoding>
                <system value="http://fhir.de/CodeSystem/bfarm/icd-10-gm" />
            </patternCoding>
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="http://fhir.de/ValueSet/bfarm/icd-10-gm" />
            </binding>
            <mapping>
                <identity value="LogicalModel" />
                <map value="ICD10GMDiagnoseKodiert" />
            </mapping>
        </element>
        <element id="Condition.code.coding:icd10-gm.system">
            <path value="Condition.code.coding.system" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:icd10-gm.version">
            <path value="Condition.code.coding.version" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:icd10-gm.code">
            <path value="Condition.code.coding.code" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="ICD10GMDiagnoseKodiert.Diagnosecode" />
            </mapping>
        </element>
        <element id="Condition.code.coding:alpha-id">
            <path value="Condition.code.coding" />
            <sliceName value="alpha-id" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Coding" />
                <profile value="http://fhir.de/StructureDefinition/CodingAlphaID" />
            </type>
            <patternCoding>
                <system value="http://fhir.de/CodeSystem/bfarm/alpha-id" />
            </patternCoding>
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="http://fhir.de/ValueSet/bfarm/alpha-id" />
            </binding>
            <mapping>
                <identity value="LogicalModel" />
                <map value="ALPHAIDKodiert" />
            </mapping>
        </element>
        <element id="Condition.code.coding:alpha-id.system">
            <path value="Condition.code.coding.system" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:alpha-id.code">
            <path value="Condition.code.coding.code" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="ALPHAIDKodiert.Diagnosecode" />
            </mapping>
        </element>
        <element id="Condition.code.coding:sct">
            <path value="Condition.code.coding" />
            <sliceName value="sct" />
            <min value="0" />
            <max value="1" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
            </patternCoding>
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/ValueSet/diagnoses-sct" />
            </binding>
            <mapping>
                <identity value="LogicalModel" />
                <map value="SNOMEDDiagnoseKodiert" />
            </mapping>
        </element>
        <element id="Condition.code.coding:sct.system">
            <path value="Condition.code.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:sct.version">
            <path value="Condition.code.coding.version" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:sct.code">
            <path value="Condition.code.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="SNOMEDDiagnoseKodiert.Diagnosecode" />
            </mapping>
        </element>
        <element id="Condition.code.coding:orphanet">
            <path value="Condition.code.coding" />
            <sliceName value="orphanet" />
            <min value="0" />
            <max value="1" />
            <patternCoding>
                <system value="http://www.orpha.net" />
            </patternCoding>
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="ORPHANETDiagnoseKodiert" />
            </mapping>
        </element>
        <element id="Condition.code.coding:orphanet.system">
            <path value="Condition.code.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:orphanet.code">
            <path value="Condition.code.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="ORPHANETDiagnoseKodiert.Diagnosecode" />
            </mapping>
        </element>
        <element id="Condition.code.coding:icd-o-3">
            <path value="Condition.code.coding" />
            <sliceName value="icd-o-3" />
            <short value="ICD-O-3 Morphologie" />
            <min value="0" />
            <max value="1" />
            <patternCoding>
                <system value="http://terminology.hl7.org/CodeSystem/icd-o-3" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:icd-o-3.system">
            <path value="Condition.code.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:icd-o-3.version">
            <path value="Condition.code.coding.version" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:icd-o-3.code">
            <path value="Condition.code.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.text">
            <path value="Condition.code.text" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="Freitextbeschreibung" />
            </mapping>
        </element>
        <element id="Condition.bodySite">
            <path value="Condition.bodySite" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="Koerperstelle" />
            </mapping>
        </element>
        <element id="Condition.bodySite.coding">
            <path value="Condition.bodySite.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="system" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:snomed-ct">
            <path value="Condition.bodySite.coding" />
            <sliceName value="snomed-ct" />
            <min value="1" />
            <max value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:snomed-ct.system">
            <path value="Condition.bodySite.coding.system" />
            <min value="1" />
            <patternUri value="http://snomed.info/sct" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:snomed-ct.version">
            <path value="Condition.bodySite.coding.version" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:snomed-ct.code">
            <path value="Condition.bodySite.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:icd-o-3">
            <path value="Condition.bodySite.coding" />
            <sliceName value="icd-o-3" />
            <short value="ICD-O-3 Topographie" />
            <min value="0" />
            <max value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:icd-o-3.system">
            <path value="Condition.bodySite.coding.system" />
            <min value="1" />
            <patternUri value="http://terminology.hl7.org/CodeSystem/icd-o-3" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.bodySite.coding:icd-o-3.code">
            <path value="Condition.bodySite.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.subject">
            <path value="Condition.subject" />
            <type>
                <code value="Reference" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Group" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.encounter">
            <path value="Condition.encounter" />
            <type>
                <code value="Reference" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Encounter" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.onset[x]">
            <path value="Condition.onset[x]" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <type>
                <code value="dateTime" />
            </type>
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetPeriod">
            <path value="Condition.onset[x]" />
            <sliceName value="onsetPeriod" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum.Zeitraum" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetPeriod.start">
            <path value="Condition.onset[x].start" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum.Zeitraum.von" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von">
            <path value="Condition.onset[x].start.extension" />
            <sliceName value="lebensphase-von" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="http://fhir.de/StructureDefinition/lebensphase" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von.value[x]:valueCodeableConcept">
            <path value="Condition.onset[x].start.extension.value[x]" />
            <sliceName value="valueCodeableConcept" />
            <type>
                <code value="CodeableConcept" />
            </type>
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum.Lebensphase.von" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetPeriod.end">
            <path value="Condition.onset[x].end" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum.Zeitraum.bis" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis">
            <path value="Condition.onset[x].end.extension" />
            <sliceName value="lebensphase-bis" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="http://fhir.de/StructureDefinition/lebensphase" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis.value[x]:valueCodeableConcept">
            <path value="Condition.onset[x].end.extension.value[x]" />
            <sliceName value="valueCodeableConcept" />
            <type>
                <code value="CodeableConcept" />
            </type>
            <mapping>
                <identity value="LogicalModel" />
                <map value="KlinischRelevanterZeitraum.Lebensphase.bis" />
            </mapping>
        </element>
        <element id="Condition.onset[x]:onsetDateTime">
            <path value="Condition.onset[x]" />
            <sliceName value="onsetDateTime" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.recordedDate">
            <path value="Condition.recordedDate" />
            <min value="1" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="Dokumentationsdatum" />
            </mapping>
        </element>
        <element id="Condition.note">
            <path value="Condition.note" />
            <mustSupport value="true" />
            <mapping>
                <identity value="LogicalModel" />
                <map value="Diagnoseerlaeuterung" />
            </mapping>
        </element>
    </differential>
</StructureDefinition>
{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-diagnose-condition",
    "url": "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose",
    "version": "2024.0.0",
    "name": "MII_PR_Diagnose_Condition",
    "title": "MII PR Diagnose Condition",
    "status": "active",
    "date": "2024-02-08",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative",
    "fhirVersion": "4.0.1",
    "mapping":  [
        {
            "identity": "LogicalModel",
            "name": "FHIR-Profil zu LogicalModel Mapping"
        }
    ],
    "kind": "resource",
    "abstract": false,
    "type": "Condition",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Condition.id",
                "path": "Condition.id",
                "mustSupport": true
            },
            {
                "id": "Condition.meta",
                "path": "Condition.meta",
                "mustSupport": true
            },
            {
                "id": "Condition.meta.source",
                "path": "Condition.meta.source",
                "mustSupport": true
            },
            {
                "id": "Condition.meta.profile",
                "path": "Condition.meta.profile",
                "mustSupport": true
            },
            {
                "id": "Condition.extension:ReferenzPrimaerdiagnose",
                "path": "Condition.extension",
                "sliceName": "ReferenzPrimaerdiagnose",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://hl7.org/fhir/StructureDefinition/condition-related"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.extension:Feststellungsdatum",
                "path": "Condition.extension",
                "sliceName": "Feststellungsdatum",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://hl7.org/fhir/StructureDefinition/condition-assertedDate"
                        ]
                    }
                ],
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "Feststellungsdatum"
                    }
                ]
            },
            {
                "id": "Condition.clinicalStatus",
                "path": "Condition.clinicalStatus",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischerStatus"
                    }
                ]
            },
            {
                "id": "Condition.code",
                "path": "Condition.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding",
                "path": "Condition.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "min": 1,
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "WeitereKodiersysteme"
                    }
                ]
            },
            {
                "id": "Condition.code.coding.code",
                "path": "Condition.code.coding.code",
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "WeitereKodiersysteme.Diagnosecode"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:icd10-gm",
                "path": "Condition.code.coding",
                "sliceName": "icd10-gm",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Coding",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/CodingICD10GM"
                        ]
                    }
                ],
                "patternCoding": {
                    "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm"
                },
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "http://fhir.de/ValueSet/bfarm/icd-10-gm"
                },
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ICD10GMDiagnoseKodiert"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:icd10-gm.system",
                "path": "Condition.code.coding.system",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:icd10-gm.version",
                "path": "Condition.code.coding.version",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:icd10-gm.code",
                "path": "Condition.code.coding.code",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ICD10GMDiagnoseKodiert.Diagnosecode"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:alpha-id",
                "path": "Condition.code.coding",
                "sliceName": "alpha-id",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Coding",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/CodingAlphaID"
                        ]
                    }
                ],
                "patternCoding": {
                    "system": "http://fhir.de/CodeSystem/bfarm/alpha-id"
                },
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "http://fhir.de/ValueSet/bfarm/alpha-id"
                },
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ALPHAIDKodiert"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:alpha-id.system",
                "path": "Condition.code.coding.system",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:alpha-id.code",
                "path": "Condition.code.coding.code",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ALPHAIDKodiert.Diagnosecode"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:sct",
                "path": "Condition.code.coding",
                "sliceName": "sct",
                "min": 0,
                "max": "1",
                "patternCoding": {
                    "system": "http://snomed.info/sct"
                },
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/ValueSet/diagnoses-sct"
                },
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "SNOMEDDiagnoseKodiert"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:sct.system",
                "path": "Condition.code.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:sct.version",
                "path": "Condition.code.coding.version",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:sct.code",
                "path": "Condition.code.coding.code",
                "min": 1,
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "SNOMEDDiagnoseKodiert.Diagnosecode"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:orphanet",
                "path": "Condition.code.coding",
                "sliceName": "orphanet",
                "min": 0,
                "max": "1",
                "patternCoding": {
                    "system": "http://www.orpha.net"
                },
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ORPHANETDiagnoseKodiert"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:orphanet.system",
                "path": "Condition.code.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:orphanet.code",
                "path": "Condition.code.coding.code",
                "min": 1,
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "ORPHANETDiagnoseKodiert.Diagnosecode"
                    }
                ]
            },
            {
                "id": "Condition.code.coding:icd-o-3",
                "path": "Condition.code.coding",
                "sliceName": "icd-o-3",
                "short": "ICD-O-3 Morphologie",
                "min": 0,
                "max": "1",
                "patternCoding": {
                    "system": "http://terminology.hl7.org/CodeSystem/icd-o-3"
                },
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:icd-o-3.system",
                "path": "Condition.code.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:icd-o-3.version",
                "path": "Condition.code.coding.version",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:icd-o-3.code",
                "path": "Condition.code.coding.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.code.text",
                "path": "Condition.code.text",
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "Freitextbeschreibung"
                    }
                ]
            },
            {
                "id": "Condition.bodySite",
                "path": "Condition.bodySite",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "Koerperstelle"
                    }
                ]
            },
            {
                "id": "Condition.bodySite.coding",
                "path": "Condition.bodySite.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "system"
                        }
                    ],
                    "rules": "open"
                },
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:snomed-ct",
                "path": "Condition.bodySite.coding",
                "sliceName": "snomed-ct",
                "min": 1,
                "max": "1",
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:snomed-ct.system",
                "path": "Condition.bodySite.coding.system",
                "min": 1,
                "patternUri": "http://snomed.info/sct",
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:snomed-ct.version",
                "path": "Condition.bodySite.coding.version",
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:snomed-ct.code",
                "path": "Condition.bodySite.coding.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:icd-o-3",
                "path": "Condition.bodySite.coding",
                "sliceName": "icd-o-3",
                "short": "ICD-O-3 Topographie",
                "min": 0,
                "max": "1",
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:icd-o-3.system",
                "path": "Condition.bodySite.coding.system",
                "min": 1,
                "patternUri": "http://terminology.hl7.org/CodeSystem/icd-o-3",
                "mustSupport": true
            },
            {
                "id": "Condition.bodySite.coding:icd-o-3.code",
                "path": "Condition.bodySite.coding.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.subject",
                "path": "Condition.subject",
                "type":  [
                    {
                        "code": "Reference",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference"
                        ],
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient",
                            "http://hl7.org/fhir/StructureDefinition/Group"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.encounter",
                "path": "Condition.encounter",
                "type":  [
                    {
                        "code": "Reference",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference"
                        ],
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Encounter"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.onset[x]",
                "path": "Condition.onset[x]",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                },
                "type":  [
                    {
                        "code": "dateTime"
                    },
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetPeriod",
                "path": "Condition.onset[x]",
                "sliceName": "onsetPeriod",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum.Zeitraum"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.start",
                "path": "Condition.onset[x].start",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum.Zeitraum.von"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von",
                "path": "Condition.onset[x].start.extension",
                "sliceName": "lebensphase-von",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/lebensphase"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von.value[x]:valueCodeableConcept",
                "path": "Condition.onset[x].start.extension.value[x]",
                "sliceName": "valueCodeableConcept",
                "type":  [
                    {
                        "code": "CodeableConcept"
                    }
                ],
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum.Lebensphase.von"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.end",
                "path": "Condition.onset[x].end",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum.Zeitraum.bis"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis",
                "path": "Condition.onset[x].end.extension",
                "sliceName": "lebensphase-bis",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/lebensphase"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis.value[x]:valueCodeableConcept",
                "path": "Condition.onset[x].end.extension.value[x]",
                "sliceName": "valueCodeableConcept",
                "type":  [
                    {
                        "code": "CodeableConcept"
                    }
                ],
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "KlinischRelevanterZeitraum.Lebensphase.bis"
                    }
                ]
            },
            {
                "id": "Condition.onset[x]:onsetDateTime",
                "path": "Condition.onset[x]",
                "sliceName": "onsetDateTime",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.recordedDate",
                "path": "Condition.recordedDate",
                "min": 1,
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "Dokumentationsdatum"
                    }
                ]
            },
            {
                "id": "Condition.note",
                "path": "Condition.note",
                "mustSupport": true,
                "mapping":  [
                    {
                        "identity": "LogicalModel",
                        "map": "Diagnoseerlaeuterung"
                    }
                ]
            }
        ]
    }
}

FHIR-Element Erklärung
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. eine kodierte Diagnose MUSS enthalten sein. System frei aus Alpha-ID, SNOMED CT, Orpahanet und ICD-10-GM wählbar.
Condition.code.coding:icd10-gm.extension:Mehrfachcodierungs-Kennzeichen Innerhalb der Extension "Mehrfachcodierungs-Kennzeichen" SOLLEN die jeweiligen Sonderzeichen ("!", "+" oder "*") vom ICD-10-GM-Code getrennt erfasst werden.
Condition.code.coding:icd10-gm.extension:Seitenlokalisation Die Extension "Seitenlokalisation" SOLL zur Angabe der Seitenlokalisation in der ICD-10-GM-Codierung verwendet werden.
Condition.code.coding:icd10-gm.extension:Diagnosesicherheit Die Extension "Diagnosesicherheit" SOLL zur Angabe der Diagnosesicherung in ICD-10-GM-Codierung verwendet werden.
Condtion.bodySite OPTIONAL. Falls dieses optionale Element verwendet wird, MUSS die Körperstelle min. mit einem SNOMED-Code kodiert werden. Hierbei DARF NICHT die Lateralität angegeben werden. Diese SOLL per Condition.code.coding:icd10-gm.extension:Seitenlokalisation angegeben werden. Das Element dient dazu, zusätzliche Angaben (über den Code hinausgehend) zur Manifestation zu dokumentieren.
Condtion.subject Die Referenz zum Modul Person MUSS stets gegeben sein.
Condition.encounter Dieses Element SOLLTE NICHT zur Verknüpfung des Falls und der Diagnose verwendet werden. Ausnahme: Das Element KANN zur Verknüpfung der Diagnose mit dem Fall / Kontakt in dem die Diagnose festgestellt wird (immer ein Kontakt mit einer konkreten Versorgungsstelle!) verwendet werden. Generell SOLLTE die Verknüpfung über Encounter.diagnosis erfolgen.
Condtion.onset[x] KANN als Period oder dateTime erfasst werden. OPTIONAL zusätzlich Angabe von Lebensphase als Code mittels Extension, 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
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 Einrichtungs-Kontakt erfolgen (Siehe Modul Fall).

Mapping Logischer Datensatz zu FHIR Diagnose-Profil

FHIRLogischerDatensatz
Condition.extension:FeststellungsdatumFeststellungsdatum
Condition.clinicalStatusKlinischerStatus
Condition.code.codingWeitereKodiersysteme
Condition.code.coding.codeWeitereKodiersysteme.Diagnosecode
Condition.code.coding:icd10-gmICD10GMDiagnoseKodiert
Condition.code.coding:icd10-gm.codeICD10GMDiagnoseKodiert.Diagnosecode
Condition.code.coding:alpha-idALPHAIDKodiert
Condition.code.coding:alpha-id.codeALPHAIDKodiert.Diagnosecode
Condition.code.coding:sctSNOMEDDiagnoseKodiert
Condition.code.coding:sct.codeSNOMEDDiagnoseKodiert.Diagnosecode
Condition.code.coding:orphanetORPHANETDiagnoseKodiert
Condition.code.coding:orphanet.codeORPHANETDiagnoseKodiert.Diagnosecode
Condition.code.textFreitextbeschreibung
Condition.bodySiteKoerperstelle
Condition.onset[x]KlinischRelevanterZeitraum
Condition.onset[x]:onsetPeriodKlinischRelevanterZeitraum.Zeitraum
Condition.onset[x]:onsetPeriod.startKlinischRelevanterZeitraum.Zeitraum.von
Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von.value[x]:valueCodeableConceptKlinischRelevanterZeitraum.Lebensphase.von
Condition.onset[x]:onsetPeriod.endKlinischRelevanterZeitraum.Zeitraum.bis
Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis.value[x]:valueCodeableConceptKlinischRelevanterZeitraum.Lebensphase.bis
Condition.recordedDateDokumentationsdatum
Condition.noteDiagnoseerlaeuterung

FHIR Element Logischer Datensatz
Encounter.period.start Diagnose.Feststellungsdatum

Es sind die Invarianten aus den Deutschen Basisprofilen zum Datentyp Profil 'Coding-Profil für ICD-10-GM' und der Extension zur Diagnosesicherheit zu beachten.


Terminology Bindings

PathNameStrengthURL
Condition.code.codingbfarm/icd-10-gmrequiredhttp://fhir.de/ValueSet/bfarm/icd-10-gm
Condition.code.codingbfarm/alpha-idrequiredhttp://fhir.de/ValueSet/bfarm/alpha-id
Condition.code.codingdiagnoses-sctrequiredhttps://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/ValueSet/diagnoses-sct

Suchparameter

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

  1. Der Suchparameter "_id" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?_id=12345

    Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".

  2. Der Suchparameter "_profile" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?_profile=https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose

    Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".

  3. Der Suchparameter "code" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?code=/Condition??code=http://fhir.de/CodeSystem/bfarm/icd-10-gm|A15.0

    Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.code" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

  4. Der Suchparameter "subject" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?subject=Patient/test

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

  5. Der Suchparameter "patient" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?patient=Patient/test

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

  6. Der Suchparameter "icd10gm-diagnosesicherheit" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?icd10gm-diagnosesicherheit=https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT|G

    Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.code.coding.extension.where(url='http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit').value" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".

  7. Der Suchparameter "icd10gm-mehrfachcodierung" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?icd10gm-mehrfachcodierung=http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen|†

    Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.code.coding.extension.where(url='http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen').value" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".

  8. Der Suchparameter "icd10gm-seitenlokalisation" MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?icd10gm-seitenlokalisation=https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION|B

    Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.code.coding.extension.where(url = 'http://fhir.de/StructureDefinition/seitenlokalisation').value" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".


Beispiele

Beispiel 1

ICD-10-GM & SNOMED CT:

{
    "resourceType": "Condition",
    "id": "mii-exa-diagnose-condition-minimal",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "version": "2020",
                "code": "S50.0",
                "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
                "display": "Prellung des Ellenbogens"
            },
            {
                "code": "91613004",
                "system": "http://snomed.info/sct",
                "version": "http://snomed.info/sct/900000000000207008/version/20230731",
                "display": "Contusion of elbow (disorder)"
            }
        ],
        "text": "Prellung des linken Ellenbogens"
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "encounter": {
        "reference": "Encounter/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 2

ICD-10-GM Diagnose mit Kreuz-Stern-System und Zusatzkennzeichen plus Alpha-ID:

{
    "resourceType": "Condition",
    "id": "mii-exa-diagnose-mehrfachkodierung-primaercode",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0"
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit",
                        "valueCoding": {
                            "code": "G",
                            "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/seitenlokalisation",
                        "valueCoding": {
                            "code": "L",
                            "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION",
                            "display": "links"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen",
                        "valueCoding": {
                            "code": "",
                            "system": "http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen"
                        }
                    }
                ],
                "code": "A54.4",
                "version": "2020",
                "display": "Gonokokkeninfektion des Muskel-Skelett-Systems"
            },
            {
                "system": "http://fhir.de/CodeSystem/bfarm/alpha-id",
                "code": "I97525",
                "version": "2020",
                "display": "Bursitis gonorrhoica"
            }
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "code": "confirmed",
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
            }
        ]
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "encounter": {
        "reference": "Encounter/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"
}

{
    "resourceType": "Condition",
    "id": "mii-exa-diagnose-mehrfachkodierung-sekundaercode",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0"
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen",
                        "valueCoding": {
                            "code": "*",
                            "system": "http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen"
                        }
                    }
                ],
                "code": "M73.04",
                "version": "2020",
                "display": "Bursitis gonorrhoica[A54.4] : Hand"
            }
        ]
    },
    "extension":  [
        {
            "url": "http://hl7.org/fhir/StructureDefinition/condition-related",
            "valueReference": {
                "reference": "Condition/mii-exa-diagnose-mehrfachkodierung-primaercode"
            }
        }
    ],
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "code": "confirmed",
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status"
            }
        ]
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "encounter": {
        "reference": "Encounter/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 3

Alpha-ID und Orpha-Kennnummer:

{
    "resourceType": "Condition",
    "id": "mii-exa-diagnose-multiple-kodierungen",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0"
        ]
    },
    "extension":  [
        {
            "url": "http://hl7.org/fhir/StructureDefinition/condition-assertedDate",
            "valueDateTime": "2020-02-13"
        }
    ],
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "version": "2020",
                "code": "H83.8",
                "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
                "display": "Sonstige näher bezeichnete Krankheiten des Innenohres"
            },
            {
                "code": "I125918",
                "system": "http://fhir.de/CodeSystem/bfarm/alpha-id",
                "version": "2020"
            },
            {
                "code": "420402",
                "system": "http://www.orpha.net",
                "display": "Bogengangsdehiszenz-Syndrom"
            }
        ]
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "encounter": {
        "reference": "Encounter/12345"
    },
    "onsetPeriod": {
        "start": "2020-02-13T16:56:00+01:00"
    },
    "recordedDate": "2020-04-26T12:00:00+01:00"
}