ISiK Basis Implementierungsleitfaden
Version 6.0.0-rc - ci-build

Resource Profile: ISiKDiagnose

Official URL: https://gematik.de/fhir/isik/StructureDefinition/ISiKDiagnose Version: 6.0.0-rc
Active as of 2025-12-17 Computable Name: ISiKDiagnose

Dieses Profil spezifiziert die Minimalanforderungen für die Bereitstellung von Informationen über die Diagnosen eines Patienten im Rahmen des Bestätigungsverfahrens der gematik.

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

Für das Profil ISiKDiagnose wird eine Kompatibilität mit folgenden Profilen angestrebt; allerdings kann nicht sichergestellt werden, dass Instanzen, die gegen ISiKDiagnose valide sind, auch valide sind gegen:

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5, isik-con1
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... clinicalStatus ?!SΣC 0..1 CodeableConcept klinischer Status
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 0..1 CodeableConcept Bestätigungsstatus
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... code SΣC 1..1 CodeableConcept Diagnose-Code
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
Constraints: icd-text-1
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM SΣ 0..1 ISiKICD10GMCoding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... Slices for extension Content/Rules for all slices
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen
Binding: Mehrfachkodierungs-Kennzeichen ICD10GM ValueSet (required)
....... extension:Seitenlokalisation S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/seitenlokalisation
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
....... extension:Diagnosesicherheit S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required)
...... system SΣ 1..1 uri System
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version SΣ 1..1 string Version
...... code SΣC 1..1 code Code
Constraints: icd-regex
Example Einfacher ICD-Code: F17.4
...... display SΣ 0..1 string Display
..... coding:Alpha-ID SΣ 0..1 CodingAlphaID Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Canonische CodeSystem URL für Alpha-ID
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version Σ 1..1 string Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code SΣ 1..1 code Der Alpha-ID-Code
..... coding:SNOMED-CT SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:Orphanet SΣ 0..1 Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
... subject SΣ 1..1 Reference(Patient | Group) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... Slices for onset[x] SΣ 0..1 Erkrankungsbeginn
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge SΣ 0..1 Age Erkrankungsbeginn als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
... Slices for abatement[x] SC 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge SC 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... abatement[x]:abatementDateTime SC 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate SΣ 1..1 dateTime Dokumentationsdatum
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.onset[x]:onsetAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.abatement[x]:abatementAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
icd-regex warning Condition.code.coding:ICD-10-GM.code In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: isik-con1
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... verificationStatus S 0..1 CodeableConcept Bestätigungsstatus
... code SC 1..1 CodeableConcept Diagnose-Code
Constraints: icd-text-1
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM S 0..1 ISiKICD10GMCoding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... Slices for extension Content/Rules for all slices
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 ExtensionMehrfachcodierungKennzeichen Optional Extensions Element
....... extension:Seitenlokalisation S 0..1 ExtensionSeitenlokalisation Optional Extensions Element
....... extension:Diagnosesicherheit S 0..1 ExtensionICD10GMDiagnosesicherheit Optional Extensions Element
..... coding:Alpha-ID S 0..1 CodingAlphaID Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... system S 1..1 uri Canonische CodeSystem URL für Alpha-ID
...... code S 1..1 code Der Alpha-ID-Code
..... coding:SNOMED-CT S 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... coding:Orphanet S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... system S 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
... bodySite S 0..* CodeableConcept Körperstelle
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct S 0..1 ISiKSnomedCTCoding Code defined by a terminology system
... subject S 1..1 Reference(Patient | Group) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... Slices for onset[x] S 0..1 Erkrankungsbeginn
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime S 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge S 0..1 Age Erkrankungsbeginn als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
... Slices for abatement[x] S 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge S 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
.... abatement[x]:abatementDateTime S 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate S 1..1 dateTime Dokumentationsdatum
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG

Constraints

Id Grade Path(s) Description Expression
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5, isik-con1
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!SΣC 0..1 CodeableConcept klinischer Status
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 0..1 CodeableConcept Bestätigungsstatus
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣC 1..1 CodeableConcept Diagnose-Code
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
Constraints: icd-text-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM SΣ 0..1 ISiKICD10GMCoding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen
Binding: Mehrfachkodierungs-Kennzeichen ICD10GM ValueSet (required)
....... extension:Seitenlokalisation S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/seitenlokalisation
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
....... extension:Diagnosesicherheit S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required)
...... system SΣ 1..1 uri System
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version SΣ 1..1 string Version
...... code SΣC 1..1 code Code
Constraints: icd-regex
Example Einfacher ICD-Code: F17.4
...... display SΣ 0..1 string Display
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:Alpha-ID SΣ 0..1 CodingAlphaID Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Canonische CodeSystem URL für Alpha-ID
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version Σ 1..1 string Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code SΣ 1..1 code Der Alpha-ID-Code
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:SNOMED-CT SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:Orphanet SΣ 0..1 Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... Slices for onset[x] SΣ 0..1 Erkrankungsbeginn
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge SΣ 0..1 Age Erkrankungsbeginn als Alter
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
..... value Σ 0..1 decimal Numerical value (with implicit precision)
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit Σ 0..1 string Unit representation
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
... Slices for abatement[x] SC 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge SC 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
..... value Σ 0..1 decimal Numerical value (with implicit precision)
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit Σ 0..1 string Unit representation
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
.... abatement[x]:abatementDateTime SC 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate SΣ 1..1 dateTime Dokumentationsdatum
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.onset[x]:onsetAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.abatement[x]:abatementAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
icd-regex warning Condition.code.coding:ICD-10-GM.code In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()
ElementShort descriptionNotes
Condition.abatement[x] Klinische relevanter Zeitraum Ende

Ende des klinisch relevanten Zeitraums der Diagnose
Begründung MS: Die Kenntnis des Erkrankungszeitraumes ist wichtig für die korrekte Einschätzung der medizinischen Relevanz einer Erkraknung.
Einschränkung der übergreifenden MS-Definition: Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Erkrankungszeitraumes, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch klinischen Status (active/inactive/resolved…) der Diagnose korrekt angeben, sofern die Information verfügbar ist.
Condition.abatement[x]:abatementAge Klinische relevanter Zeitraum Ende als Alter

'’Begründung MS:** Siehe abatement[x]
Condition.abatement[x]:abatementDateTime Klinische relevanter Zeitraum Ende als Datum

'’Begründung MS:** Siehe abatement[x]
Condition.bodySite Körperstelle

Begründung MS: Harmonisierung mit KBV-Profil (KBV_PR_Base_Condition_Diagnosis)
Condition.bodySite.coding
Condition.bodySite.coding:snomed-ct
Condition.clinicalStatus klinischer Status

Begründung MS: Auch in Stufe 4 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.
Einschränkung 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 clinicalStatus befüllen, sofern die entsprechende Information verfügbar ist.
Hinweis: Für Diagnosen aus der ambulanten Versorgung können die Werte für clinicalStatus und verificationStatus aus dem ICD-10-Zusatzkennzeichen für die Diagnosesicherheit abgeleitet werden. Das entsprechende Mapping kann den Deutschen Basisprofilen entnommen werden.
Condition.code Diagnose-Code

Diagnosen SOLLEN mindestens entweder mit einem der angebenen standardisierten Codier-Verfahren codiert werden. Ist keine Codierung möglich, MUSS statt dessen eine textuelle Beschreibung der Prozedur angegeben werden.
Begründung Pflichtfeld: Ist weder eine Codierung noch eine textuelle Beschreibung vorhanden, besitzt diese Ressource keine medizinische Aussagefähigkeit.
Condition.code.coding
Condition.code.coding:Alpha-ID
Condition.code.coding:Alpha-ID.code
Condition.code.coding:Alpha-ID.system
Condition.code.coding:ICD-10-GM
Condition.code.coding:ICD-10-GM.extension:Diagnosesicherheit
Condition.code.coding:ICD-10-GM.extension:Mehrfachcodierungs-Kennzeichen
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation
Condition.code.coding:Orphanet
Condition.code.coding:Orphanet.system
Condition.code.coding:SNOMED-CT
Condition.encounter Aufenthaltsbezug

Begründung Must-Support: Ein Aufenthaltsbezug der Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Condition.encounter.reference Encounter-Link

Begründung Pflichtfeld: Die Verlinkung auf eine Encounter-Ressource dient der technischen Zuordnung der Dokumentation zu einem Aufenthalt und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. WICHTIGER Hinweis für Implementierer: Die Zuordnung MUSS auf einen Encounter der Ebene “Abteilungskontakt” (siehe hierzu Basismodul > UseCases > Abbildung des Konstruktes “Fall”) erfolgen.
Bei der Auswahl des Encounters ist zu beachten, dass unter einer (Abrechnungs-)”Fallnummer” (hier: Encounter.account) unter Umständen mehrere Encounter gruppiert sein können (z.B. stationärer Besuch mit mehreren vor- und nachstationären Aufenthalten.) Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKKontaktGesundheitseinrichtung sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Condition.extension
Condition.extension:related Verknüpfte Diagnose

Die Deutschen Kodierrichtlinien und die ‘German Modification’ ermöglichen es teilweise, ICD-10-Codierte Diagnosen miteinander zu verknüpfen (‘Kreuz-Stern-Ausrufezeichen-Notation’), diese aber dennoch wie eigenständige Diagnosen (mit jeweils eigener Diagnosesicherheit oder -Lokalisation) zu kommunizieren. Daher ist es in Deutschland nicht möglich, dem internationalen Usus zu folgen und verknüpfte Diagnosen als postkoordinierten Code einer Condition-Ressource aufzufassen. Statt dessen müssen sie zwei eigenständige Condition-Ressourcen abgebildet werden, die mit Hilfe der related-Extension miteinander verknüpft werden.
Die Sekundärdiagnose verweist jeweils auf die Primärdiagnose.
Condition.id serverseitige, interne ID des Datensatzes

bedingtes Pflichtfeld/bedingtes MS: Alle von einem Server bereitgestellten Ressourcen MÜSSEN über eine id verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine idverfügen.
Condition.note Notizen

Ergänzende Hinweise und Anmerkungen zur Diagnose
Condition.onset[x] Erkrankungsbeginn

Datum oder Alter/Lebensphase des Erkrankungsbeginns Begründung MS: Die Kenntnis des Erkrankungszeitraumes ist wichtig für die korrekte Einschätzung der medizinischen Relevanz einer Erkraknung.
Einschränkung der übergreifenden MS-Definition: Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Erkrankungszeitraumes, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch klinischen Status (active/inactive/resolved…) der Diagnose korrekt angeben, sofern die Information verfügbar ist.
Condition.onset[x]:onsetAge Erkrankungsbeginn als Alter

'’Begründung MS:** Siehe onset[x]
Condition.onset[x]:onsetDateTime Erkrankungsbeginn als Datum

'’Begründung MS:** Siehe onset[x]
Condition.recordedDate Dokumentationsdatum

Datum, an dem die Diagnose dokumentiert wurde.
Begründung Pflichtfeld: 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.
Hinweis: Das Recorded Date MUSS mindestens auf den Monat genau angegeben werden.
Condition.subject Patientenbezug

Begründung Must-Support: Ein Patientenbezug der Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Condition.subject.reference Patienten-Link

Begründung MS: Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKPatient sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Condition.verificationStatus Bestätigungsstatus

Einschränkung der übergreifenden MS-Definition: Die Implementierung dieses Elements ist für Server optional. Die Kennzeichnung als Must-Support erfolgt, da es sich um ein als Modifier-Element markiertes Feld in der Kernspezifikation handelt. Clients, die eine ISiKPatient-Instanz verarbeiten, SOLLEN den Wert dieses Elements vor der weiteren Verarbeitung prüfen.

WICHTIGER Hinweis für Implementierer:

  • Alle server-seitigen Implementierungen SOLLEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens aber den Status ‘confirmed’.
  • Alle client-seitigen Implementierungen SOLLEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können.

This structure is derived from Condition

Summary

Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 32 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.code.coding
  • The element 1 is sliced based on the value of Condition.bodySite.coding
  • The element 1 is sliced based on the value of Condition.onset[x]
  • The element 1 is sliced based on the value of Condition.abatement[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5, isik-con1
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... clinicalStatus ?!SΣC 0..1 CodeableConcept klinischer Status
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 0..1 CodeableConcept Bestätigungsstatus
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... code SΣC 1..1 CodeableConcept Diagnose-Code
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
Constraints: icd-text-1
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM SΣ 0..1 ISiKICD10GMCoding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... Slices for extension Content/Rules for all slices
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen
Binding: Mehrfachkodierungs-Kennzeichen ICD10GM ValueSet (required)
....... extension:Seitenlokalisation S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/seitenlokalisation
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
....... extension:Diagnosesicherheit S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required)
...... system SΣ 1..1 uri System
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version SΣ 1..1 string Version
...... code SΣC 1..1 code Code
Constraints: icd-regex
Example Einfacher ICD-Code: F17.4
...... display SΣ 0..1 string Display
..... coding:Alpha-ID SΣ 0..1 CodingAlphaID Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Canonische CodeSystem URL für Alpha-ID
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version Σ 1..1 string Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code SΣ 1..1 code Der Alpha-ID-Code
..... coding:SNOMED-CT SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:Orphanet SΣ 0..1 Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
... subject SΣ 1..1 Reference(Patient | Group) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... Slices for onset[x] SΣ 0..1 Erkrankungsbeginn
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge SΣ 0..1 Age Erkrankungsbeginn als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
... Slices for abatement[x] SC 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge SC 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... abatement[x]:abatementDateTime SC 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate SΣ 1..1 dateTime Dokumentationsdatum
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.onset[x]:onsetAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.abatement[x]:abatementAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
icd-regex warning Condition.code.coding:ICD-10-GM.code In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()

Differential View

This structure is derived from Condition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: isik-con1
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... verificationStatus S 0..1 CodeableConcept Bestätigungsstatus
... code SC 1..1 CodeableConcept Diagnose-Code
Constraints: icd-text-1
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM S 0..1 ISiKICD10GMCoding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... Slices for extension Content/Rules for all slices
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 ExtensionMehrfachcodierungKennzeichen Optional Extensions Element
....... extension:Seitenlokalisation S 0..1 ExtensionSeitenlokalisation Optional Extensions Element
....... extension:Diagnosesicherheit S 0..1 ExtensionICD10GMDiagnosesicherheit Optional Extensions Element
..... coding:Alpha-ID S 0..1 CodingAlphaID Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... system S 1..1 uri Canonische CodeSystem URL für Alpha-ID
...... code S 1..1 code Der Alpha-ID-Code
..... coding:SNOMED-CT S 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
..... coding:Orphanet S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... system S 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
... bodySite S 0..* CodeableConcept Körperstelle
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct S 0..1 ISiKSnomedCTCoding Code defined by a terminology system
... subject S 1..1 Reference(Patient | Group) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... Slices for onset[x] S 0..1 Erkrankungsbeginn
Slice: Unordered, Open by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime S 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge S 0..1 Age Erkrankungsbeginn als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
... Slices for abatement[x] S 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Open by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge S 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... Slices for extension Content/Rules for all slices
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
.... abatement[x]:abatementDateTime S 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate S 1..1 dateTime Dokumentationsdatum
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG

Constraints

Id Grade Path(s) Description Expression
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Condition C 0..* Condition Detailed information about conditions, problems or diagnoses
Constraints: con-3, con-4, con-5, isik-con1
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension S 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose
URL: http://hl7.org/fhir/StructureDefinition/condition-related
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier External Ids for this condition
... clinicalStatus ?!SΣC 0..1 CodeableConcept klinischer Status
Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis.
... verificationStatus ?!SΣC 0..1 CodeableConcept Bestätigungsstatus
Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis.
... category 0..* CodeableConcept problem-list-item | encounter-diagnosis
Binding: ConditionCategoryCodes (extensible): A category assigned to the condition.
... severity 0..1 CodeableConcept Subjective severity of condition
Binding: Condition/DiagnosisSeverity (preferred): A subjective assessment of the severity of the condition as evaluated by the clinician.
... code SΣC 1..1 CodeableConcept Diagnose-Code
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis.
Constraints: icd-text-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:ICD-10-GM SΣ 0..1 ISiKICD10GMCoding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... extension:Mehrfachcodierungs-Kennzeichen S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen
Binding: Mehrfachkodierungs-Kennzeichen ICD10GM ValueSet (required)
....... extension:Seitenlokalisation S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/seitenlokalisation
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required)
....... extension:Diagnosesicherheit S 0..1 Coding Optional Extensions Element
URL: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit
Binding: https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required)
...... system SΣ 1..1 uri System
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version SΣ 1..1 string Version
...... code SΣC 1..1 code Code
Constraints: icd-regex
Example Einfacher ICD-Code: F17.4
...... display SΣ 0..1 string Display
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:Alpha-ID SΣ 0..1 CodingAlphaID Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Canonische CodeSystem URL für Alpha-ID
Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id
...... version Σ 1..1 string Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
...... code SΣ 1..1 code Der Alpha-ID-Code
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:SNOMED-CT SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
Binding: DiagnosesSCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:Orphanet SΣ 0..1 Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://www.orpha.net
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... bodySite SΣ 0..* CodeableConcept Körperstelle
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:snomed-ct SΣ 0..1 ISiKSnomedCTCoding Code defined by a terminology system
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Group) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... Slices for onset[x] SΣ 0..1 Erkrankungsbeginn
Slice: Unordered, Closed by type:$this
.... onsetDateTime dateTime
.... onsetAge Age
.... onset[x]:onsetDateTime SΣ 0..1 dateTime Erkrankungsbeginn als Datum
.... onset[x]:onsetAge SΣ 0..1 Age Erkrankungsbeginn als Alter
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns
URL: http://fhir.de/StructureDefinition/lebensphase
..... value Σ 0..1 decimal Numerical value (with implicit precision)
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit Σ 0..1 string Unit representation
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
... Slices for abatement[x] SC 0..1 Klinische relevanter Zeitraum Ende
Slice: Unordered, Closed by type:$this
.... abatementDateTime dateTime
.... abatementAge Age
.... abatement[x]:abatementAge SC 0..1 Age Klinische relevanter Zeitraum Ende als Alter
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes
URL: http://fhir.de/StructureDefinition/lebensphase
..... value Σ 0..1 decimal Numerical value (with implicit precision)
..... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
..... unit Σ 0..1 string Unit representation
..... system ΣC 0..1 uri System that defines coded unit form
..... code Σ 0..1 code Coded form of the unit
.... abatement[x]:abatementDateTime SC 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum
... recordedDate SΣ 1..1 dateTime Dokumentationsdatum
... recorder Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Who recorded the condition
... asserter Σ 0..1 Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Person who asserts this condition
... stage C 0..* BackboneElement Stage/grade, usually assessed formally
Constraints: con-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... summary C 0..1 CodeableConcept Simple summary (disease specific)
Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages).
.... assessment C 0..* Reference(ClinicalImpression | DiagnosticReport | Observation) Formal record of assessment
.... type 0..1 CodeableConcept Kind of staging
Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological).
... evidence C 0..* BackboneElement Supporting evidence
Constraints: con-2
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code ΣC 0..* CodeableConcept Manifestation/symptom
Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition.
.... detail ΣC 0..* Reference(Resource) Supporting information found elsewhere
... note S 0..* Annotation Notizen

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Condition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Condition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Condition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Condition.clinicalStatus Base required Condition Clinical Status Codes 📍4.0.1 FHIR Std.
Condition.verificationStatus Base required ConditionVerificationStatus 📍4.0.1 FHIR Std.
Condition.category Base extensible Condition Category Codes 📍4.0.1 FHIR Std.
Condition.severity Base preferred Condition/Diagnosis Severity 📍4.0.1 FHIR Std.
Condition.code Base example Condition/Problem/Diagnosis Codes 📍4.0.1 FHIR Std.
Condition.code.coding:SNOMED-CT Base required DiagnosesSCT 📦6.0.0-rc This IG
Condition.bodySite Base example SNOMED CT Body Structures 📍4.0.1 FHIR Std.
Condition.subject.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Condition.onset[x]:onsetAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.abatement[x]:abatementAge.​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Condition.stage.summary Base example Condition Stage 📍4.0.1 FHIR Std.
Condition.stage.type Base example Condition Stage Type 📍4.0.1 FHIR Std.
Condition.evidence.code Base example Manifestation and Symptom Codes 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
con-1 error Condition.stage Stage SHALL have summary or assessment summary.exists() or assessment.exists()
con-2 error Condition.evidence evidence SHALL have code or details code.exists() or detail.exists()
con-3 best practice Condition Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
con-4 error Condition If condition is abated, then clinicalStatus must be either inactive, resolved, or remission abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
con-5 error Condition Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
dom-2 error Condition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Condition If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Condition If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Condition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Condition A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
icd-regex warning Condition.code.coding:ICD-10-GM.code In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')
icd-text-1 error Condition.code Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt. coding.exists().not() implies text.exists()
isik-con1 error Condition Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte. code.coding.exists() implies encounter.exists()

This structure is derived from Condition

Summary

Mandatory: 3 elements(3 nested mandatory elements)
Must-Support: 32 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Condition.code.coding
  • The element 1 is sliced based on the value of Condition.bodySite.coding
  • The element 1 is sliced based on the value of Condition.onset[x]
  • The element 1 is sliced based on the value of Condition.abatement[x]

 

Other representations of profile: CSV, Excel, Schematron