Diagnose (Condition)
Motivation
Die Möglichkeit, auf eine Übersicht der Diagnosen eines Patienten zuzugreifen, Patienten anhand ihrer Diagnose zu suchen oder zu prüfen, ob eine konkrete Diagnose bei einem Patienten vorliegt, sind wichtige Funktionen im klinischen Behandlungsablauf.
In FHIR werden Diagnosen mit der Condition-Ressource repräsentiert.
Da die Diagnosen in klinischen Primärsystemen in der Regel in ICD-10-codierter Form vorliegen, fordert ISiK in erster Linie diese Form des Austausches. Falls eine Diagnose zwar dokumentiert, aber noch nicht codiert wurde (z.B. wenn die Kodierung erst nach der Entlassung erfolgt), ist alternativ eine Repräsentation als Freitext-Diagnose möglich.
Kompatibilität
Dieses Profil basiert auf dem Profil "Diagnose" der Medizininformatik-Initative.
Instanzen, die gegen ISiKDiagnose valide sind, sind auch valide gegen:
das Profil ProfileConditionDiagnose der Medizininformatik-Initative - v2.0.0
- wenn unter
Condition.code.coding
mindestens eine codierte Darstellung der Diagnose angegeben wurde
- wenn unter
das Profil KBV_PR_Base_Diagnosis der KBV - v1.2.1
- wenn unter
Condition.code.coding
mindestens eine codierte Darstellung der Diagnose angegeben wurde
- wenn unter
das Profil KBV_PR_EAU_Condition_ICD der KBV - v1.0.2
- wenn unter
Condition.code.coding
mindestens eine ICD-10-codierte Darstellung der Diagnose angegeben wurde - wenn unter
Condition.verificationStatus
ein Wert angegeben wurde - wenn unter
Condition.asserter
eine Referenz auf einen Practitioner angegeben werden.
- wenn unter
Profil
Name | Canonical |
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ISiKDiagnose | https://gematik.de/fhir/isik/v2/Basismodul/StructureDefinition/ISiKDiagnose |
Condition | I | Condition | Element idCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idCondition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idCondition.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idCondition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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text | 0..1 | Narrative | There are no (further) constraints on this element Element idCondition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idCondition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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extension | S I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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related | S I | 0..1 | Extension(Reference(Condition)) | Element idCondition.extension:related Conditions associated with this condition Alternate namesextensions, user content DefinitionThis condition has an unspecified relationship with another condition. When the relationship is specified, use the more specific extension, such as condition-dueTo, condition-occurredFollowing, or condition-part of. Extension(Reference(Condition)) Extension URLhttp://hl7.org/fhir/StructureDefinition/condition-related Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element idCondition.identifier External Ids for this condition DefinitionBusiness identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
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clinicalStatus | S Σ ?! I | 0..1 | CodeableConceptBinding | Element idCondition.clinicalStatus active | recurrence | relapse | inactive | remission | resolved DefinitionEinschränkung der übergreifenden MS-Definition: Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Status einer Diagnose, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch den Status kodieren in der Diagnose, sofern die Information verfügbar ist. Hintergrund zur Motivation der MS-Definition: Auch in Stufe 2 sind keine (Client-seitigen) schreibenden Operationen für das Erstellen einer Condition-Ressource vorgesehen (siehe CapabilityStatement). Das heißt entweder führen KISe entsprechende Informationen und exponieren diese, oder es gibt keinen pragmatischen Mechanismus (im ISIK-Kontext), um den Use Case einer zusätzlichen Annotation mittels Client zu erfüllen. Da alle KIS-Hersteller, die sich zu Wort gemeldet haben, eine Befüllung von Condition.clinicalStatus NICHT unterstützen, erscheint das MS nach übergreifender Definition und ein verpflichtender Testfall nicht angemessen. The clinical status of the condition or diagnosis.
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verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. The verification status to support or decline the clinical status of the condition or diagnosis.
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category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition.
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severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician.
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code | S Σ I | 1..1 | CodeableConcept | Element idCondition.code Identification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 0..* | Coding | Element idCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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ICD-10-GM | S Σ | 0..1 | Coding-Profil für ICD-10-GMPattern | Element idCondition.code.coding:ICD-10-GM A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
{ "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm" }
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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Mehrfachcodierungs-Kennzeichen | S I | 0..1 | Extension(Coding) | Element idCondition.code.coding:ICD-10-GM.extension:Mehrfachcodierungs-Kennzeichen Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Constraints
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Seitenlokalisation | S I | 0..1 | Extension(Coding) | Element idCondition.code.coding:ICD-10-GM.extension:Seitenlokalisation Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/seitenlokalisation Constraints
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Diagnosesicherheit | S I | 0..1 | Extension(Coding) | Element idCondition.code.coding:ICD-10-GM.extension:Diagnosesicherheit Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints
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system | Σ | 1..1 | uriFixed ValuePattern | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.system Canonische CodeSystem URL für ICD-10-GM DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://fhir.de/CodeSystem/bfarm/icd-10-gm
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version | Σ | 1..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.version Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") DefinitionBie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ I | 1..1 | code | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.code Der ICD-10-Code DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
Einfacher ICD-Code F17.4 Mappings
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.code.coding:ICD-10-GM.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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Alpha-ID | S Σ | 0..1 | Coding-Profil für Alpha-IDPattern | Element idCondition.code.coding:Alpha-ID A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
{ "system": "http://fhir.de/CodeSystem/alpha-id" }
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | S Σ | 1..1 | uriFixed ValuePattern | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.system Canonische CodeSystem URL für Alpha-ID DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://fhir.de/CodeSystem/bfarm/alpha-id
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version | Σ | 1..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.version Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") DefinitionBie Verwendung von Alpha-ID ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von Alpha-ID ein neues Codesystem darstellt. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.code Der Alpha-ID-Code DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.code.coding:Alpha-ID.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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SNOMED-CT | S Σ | 0..1 | CodingBindingPattern | Element idCondition.code.coding:SNOMED-CT Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://snomed.info/sct" }
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://snomed.info/sct
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | S Σ | 1..1 | code | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.code.coding:SNOMED-CT.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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Orphanet | S Σ | 0..1 | CodingPattern | Element idCondition.code.coding:Orphanet Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://www.orpha.net" }
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://www.orpha.net
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idCondition.code.coding:Orphanet.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.code.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. Codes describing anatomical locations. May include laterality.
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subject | S Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element idCondition.subject Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idCondition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idCondition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idCondition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idCondition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | S Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
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onset[x] | Σ | 0..1 | Element idCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur. Unordered, Closed, by $this(Type) Constraints
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onsetPeriod | Σ | 0..1 | Period | Element idCondition.onset[x]:onsetPeriod Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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start | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.start Starting time with inclusive boundary DefinitionThe start of the period. The boundary is inclusive. If the low element is missing, the meaning is that the low boundary is not known.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.start.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.start.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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Lebensphase-Start | I | 0..1 | Extension(CodeableConcept) | Element idCondition.onset[x]:onsetPeriod.start.extension:Lebensphase-Start Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/lebensphase Constraints
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value | 0..1 | System.DateTime | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.start.value Primitive value for dateTime DefinitionPrimitive value for dateTime System.DateTime | |
end | Σ I | 0..1 | dateTime | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.end End time with inclusive boundary, if not ongoing DefinitionThe end of the period. If the end of the period is missing, it means no end was known or planned at the time the instance was created. The start may be in the past, and the end date in the future, which means that period is expected/planned to end at that time. The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03. If the end of the period is missing, it means that the period is ongoing
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.end.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.end.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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Lebensphase-Ende | I | 0..1 | Extension(CodeableConcept) | Element idCondition.onset[x]:onsetPeriod.end.extension:Lebensphase-Ende Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. http://fhir.de/StructureDefinition/lebensphase Constraints
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value | 0..1 | System.DateTime | There are no (further) constraints on this element Element idCondition.onset[x]:onsetPeriod.end.value Primitive value for dateTime DefinitionPrimitive value for dateTime System.DateTime | |
onsetDateTime | Σ | 0..1 | dateTime | Element idCondition.onset[x]:onsetDateTime Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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abatement[x] | I | 0..1 | There are no (further) constraints on this element Element idCondition.abatement[x] When in resolution/remission DefinitionThe date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
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abatementDateTime | dateTime | There are no (further) constraints on this element Data type | ||
abatementAge | Age | There are no (further) constraints on this element Data type | ||
abatementPeriod | Period | There are no (further) constraints on this element Data type | ||
abatementRange | Range | There are no (further) constraints on this element Data type | ||
abatementString | string | There are no (further) constraints on this element Data type | ||
recordedDate | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element idCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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stage | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.stage.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.stage.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing condition stages (e.g. Cancer stages).
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assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | There are no (further) constraints on this element Element idCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing the kind of condition staging (e.g. clinical or pathological).
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evidence | I | 0..* | BackboneElement | There are no (further) constraints on this element Element idCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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id | 0..1 | string | There are no (further) constraints on this element Element idCondition.evidence.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idCondition.evidence.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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.
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code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element idCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe the manifestation or symptoms of a condition.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | S | 0..* | Annotation | There are no (further) constraints on this element Element idCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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Constraints
Folgende FHIRPath-Constraints sind im Profil zu beachten:
key | severity | human | expression |
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isik-con1 | error | Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. | code.coding.exists() implies encounter.exists() |
icd-text-1 | error | Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/R4/element.html - ele-1), ist explizit nicht erlaubt. | coding.exists().not() implies text.exists() |
Terminology Bindings
Path | Name | Strength | URL |
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Condition.code.coding | DiagnosesSCT | required | https://gematik.de/fhir/isik/v2/Basismodul/ValueSet/DiagnosesSCT |
Anmerkungen zu den Must-Support-Feldern
Condition.clinicalStatus
Bedeutung: Der kodierte klinische Status der Diagnose MUSS, sofern vorhanden, angegeben werden, da die Interpretation der Diagnose davon abhängt ob diese 'aktiv' ist oder einen anderen Status aufweist. Alle in einem System möglichen Clinical-Status-Werte MÜSSEN, sofern vorhanden, über FHIR korrekt repräsentiert werden, können mindestens jedoch die Status-Werte "active" und "inactive" unterstützen.
Hinweise:
FHIRPath Constraints seitens der FHIR-Kernspezifikation rund um Condition.clinicalStatus sind zu beachten.
Condition.code.coding
Bedeutung: Kodierte Diagnose. Die Kodierung KANN nach den Vorgaben des BfArM per ICD-10GM kodiert werden. Weiterhin sind folgende Kodiersysteme u.a. auf Basis von Empfehlungen des BfArM zulässig:
Condition.code.text
Bedeutung: Freitextdiagnose
Hinweise:
Die Freitextdiagnose darf nur alleinstehend angegeben werden, solange keine kodierte Diagnose vorliegt.
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation
Hinweise: Angaben zur ICD-Seitenlokalisation ("R", "L", "B") müssen vom Code abgetrennt und in der Extension angegeben werden.
Condition.code.coding:ICD-10-GM.extension:Mehrfachcodierungs-Kennzeichen
Hinweise: ICD-Mehfachcodierungs-Kennzeichen ("†", "*", "!") müssen vom Code abgetrennt und in der Extension angegeben werden.
Condition.code.coding:ICD-10-GM.extension:Diagnosesicherheit
Hinweise: Angaben zur ICD-Diagnosesicherheit ("A", "G", "V", "Z") müssen vom Code abgetrennt und in der Extension angegeben werden.
Condition.subject
Bedeutung: Ein Patientenbezug der Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Condition.encounter
Bedeutung: Der Fallbezug einer Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Hinweise:
Eine Verlinkung der Referenz auf den dazugehörigen Kontakt SOLL auf die Ebene des Abteilungskontaktes (entsprechend ISiKKontaktGesundheitseinrichtung) erfolgen. Bei der Auswahl des Kontaktes ist zu beachten, dass mehrere Encounter-Ressourcen mit identischen Aufnahmenummer-Identifiern existieren können (Abbildung Vor- und nachstationäre Kontakte).
Condition.recordedDate
Bedeutung: Das Dokumentationsdatum der Diagnose MUSS zu Qualitätssicherungszwecken angegeben werden. Dies ist das fachliche Dokumentationsdatum, nicht zu verwechseln mit der technischen Anlage des Datensatzes im Primärsystem. Diese beiden Daten können jedoch identisch sein.
Hinweise:
Das Recorded Date MUSS mindestens auf den Monat genau angegeben werden (vgl. FHIRPath Constraint rec-1)
Condition.note
Bedeutung: Weitere optionale Freitext-Notizen bezogen auf die Diagnose.
Condition.extension:ReferenzPrimaerdiagnose
Bedeutung: Bei mehrfachkodierten ICD-Diagnosen (z.B. Kreuz-Stern-Notation) muss die Sekundär- auf die Primärdiagnose verlinkt werden
Interaktionen
Für die Ressource Condition MUSS die REST-Interaktion "READ" implementiert werden.
Folgende Suchparameter sind für das Bestätigungsverfahren relevant, auch in Kombination:
Der Suchparameter "_id" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?_id=test
Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "clinical-status" MUSS unterstützt werden, sofern das Element implementiert wird (siehe in der Profilstruktur Festlegung zu bedingtem Must Support):
Beispiele:
GET [base]/Condition?clincial-status=active
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.clinicalStatus" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Dieser Suchparameter ist für die Umsetzung des IHE QEDm Profils verpflichtend.
Der Suchparameter "patient" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?patient=Patient/123
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Dieser Suchparameter ist für die Umsetzung des IHE QEDm Profils verpflichtend.
Der Suchparameter "subject" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?subject=Patient/123
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "encounter" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?encounter=Patient/123
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.encounter" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".
Der Suchparameter "recorded-date" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?recorded-date=2015-01-01T12:00:23Z+02:00
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.recordedDate" finden sich in der FHIR-Basisspezifikation - Abschnitt "Date Search".
Der custom Suchparameter "related" MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?related=Condition/123
Anwendungshinweise: Weitere Informationen zur Suche nach "Condition.related" finden sich im Leitfaden Basis DE (R4) - Abschnitt "Diagnosen (Condition) - Doppel-/Mehrfachkodierte ICD-Codes".
Der Suchparameter "category" KANN unterstützt werden:
Beispiele:
GET [base]/Condition?category=http://hl7.org/fhir/ValueSet/condition-category|problem-list-item
Anwendungshinweise: Weitere Informationen zur Suche nach "category" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".
Dieser Suchparameter ist für die Umsetzung des IHE QEDm Profils verpflichtend.
Beispiel
Valides Minimalbeispiel Diagnose:
{ "resourceType": "Condition", "id": "Example-condition-kreuz-stern-primaer", "meta": { "profile": [ "https://gematik.de/fhir/isik/v2/Basismodul/StructureDefinition/ISiKDiagnose" ] }, "clinicalStatus": { "coding": [ { "code": "recurrence", "system": "http://terminology.hl7.org/CodeSystem/condition-clinical" } ] }, "code": { "coding": [ { "extension": [ { "url": "http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen", "valueCoding": { "version": "2021", "code": "†", "system": "http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen" } } ], "version": "2019", "code": "E10.30", "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm", "display": "Diabetes mellitus" } ] }, "subject": { "reference": "Patient/PatientinMusterfrau" }, "encounter": { "reference": "Encounter/Fachabteilungskontakt" }, "recordedDate": "2021-05-24", "note": [ { "text": "Beispiel für eine Anmerkung" } ] }