MII IG Symptom DE v2024

Code für ein Symptom, Phänomen, Erkrankung, Disposition: SNOMED CT (Findings), ICD-10, OrphaCodes, HPO, MedDRA

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Externer Identifikator für die Condition

Natürlichsprachige Bezeichnung für ein Symptom, Diagnose, Erkrankung, Phänotyp, Disposition

Note that FHIR strings SHALL NOT exceed 1MB in size

Natürlichsprachige Beschreibung für ein Symptom, eine Erkrankung, eine Diagnose oder eine Disposition.

Note that FHIR strings SHALL NOT exceed 1MB in size

Kategorien der Condition (z.B. problem-list-item | encounter-diagnosis)

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Lokalisation eines Symptoms etc. Körperstellen (Lokalisationen) werden SNOMED CT kodiert.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Startzeitpunkt: Zeitpunkt des Beginns des Symptoms, der Erkrankung, der Diagnose, der Disposition, des Phänotyps

Endzeitpunkt: Zeitpunkt des Verschwindens des Symptoms, der Erkrankung, der Diagnose, der Disposition, des Phänotyps

Lebensphase Start

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Lebensphase Ende

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Zeitpunkt der Beobachtung/Feststellung des Symptoms, Erkrankung, Diagnose, Disposition.

Zeitpunkt der Dokumentation das Symptoms, Erkrankung, Diagnose, Disposition

Status des Symptoms, Erkrankung, Diagnose, Disposition: "Aktiv", "Zustand nach", "in Remission", "beseitigt/geheilt"). Codiert z. B. mit ValueSet aus FHIR oder SNOMED CT.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Schweregrad des Symptoms, Erkrankung, Diagnose, Disposition. Codesystem: SNOMED CT.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Empirische, epistemologische, algorithmische, diagnostische Gewissheit des Symptoms, Erkrankung, Diagnose, Disposition. Codesystem: SNOMED CT.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Natürlichsprachige Beschreibung einer dem Symptom zugrundeliegenden Beobachtung, Symptoms, Erkrankung, Diagnose, Disposition

Note that FHIR strings SHALL NOT exceed 1MB in size

Code der zugrundeliegenden Beobachtung des Symptoms, Erkrankung, Diagnose, Disposition: SNOMED CT, LOINC

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Link auf die dem Symptom zugrundeliegenden Beobachtung für das Symptoms, Erkrankung, Diagnose, Disposition

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Einfache Zusammenfassung des Stadiums

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Referenz auf eine formale Einschätzung des Stadiums (ClinicalImpression, DiagnosticReport, Observation)

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Art der Stadieneinteilung

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Link auf Patient

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Link auf Behandlungsfall

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Eindeutiger Identifier der Observation

Natürlichsprachige Bezeichnung der Observation

Note that FHIR strings SHALL NOT exceed 1MB in size

Natürlichsprachige Beschreibung der Beobachtung

Note that FHIR strings SHALL NOT exceed 1MB in size

Kategorie der Observation

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Status der Observation

Note that FHIR strings SHALL NOT exceed 1MB in size

Code der Observation: z. B. LOINC, SNOMED CT, HPO

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Klinisch relevanter (Start-)Zeitpunkt einer Observation

Klinisch relevanter Endzeitpunkt einer Observation

Zeitpunkt der Dokumentation der Observation.

Note: This is intended for where precisely observed times are required, typically system logs etc., and not human-reported times - for them, see date and dateTime (which can be as precise as instant, but is not required to be) below. Time zone is always required

Referenz-Intervall entsprechend des eingebetteten komplexen Typs (Observation.referenceRange)

Grund für nicht vorhandene Daten der Observation

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Interpretation einer Observation

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Natürlichsprachiger Kommentar zur Observation.

For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).

Lokalisation der Observation als SNOMED CT Body Structure codiert.

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Link auf Patient

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Fall der Observation

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Referenz auf die Probe, auf der die Observation basiert

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Referenz auf das verwendete Mess-/Untersuchungsgerät

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Methode der Untersuchung

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Bezug zu Ressourcen, die zu dieser Observation gehören (Observation, QuestionnaireResponse, MolecularSequence)

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Referenz auf Messunger/Beobachtungen, aus denen diese Observation hervorgeht.

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Komponente einer Observation mit mehreren Komponenten (z. B. Blutdruck) entsprechend des komplexen Typs (Observation.component) mit .code, .value, .dataAbsentReason, .interpretation, .referenceRange (alle wie oben beschrieben)