ISiK Vitalparameter Implementierungsleitfaden
Version 6.0.0-rc - STU1

Resource Profile: ISiKGCS

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

Dieses Profil spezifiziert die Minimalanforderungen für die Bereitstellung von Informationen über den Glasgow Coma Scale (GCS) Score eines Patienten im Rahmen der interoperablen Kommunikation gemäß den Vorgaben der ISiK (Interoperable Schnittstelle im Krankenhaus).

Motivation

Die Erfassung und Überwachung des Bewusstseinszustands anhand des GCS ist essenziell für die Beurteilung neurologischer Funktionen, die Überwachung von Patienten mit Schädel-Hirn-Trauma oder anderen neurologischen Erkrankungen sowie die Unterstützung klinischer Entscheidungen.

In FHIR wird der GCS-Score mit der Observation-Ressource repräsentiert, wobei die einzelnen Komponenten der Skala - Augenöffnung, verbale Reaktion und motorische Reaktion - als Component-Elemente abgebildet werden.

Kompatibilität

Das Profil ISiKGCS ist vom Profil ScoreDE_GCS aus den deutschen Basisprofilen abgeleitet.

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
.. Observation C 0..* ScoreDE_GCS Measurements and simple assertions
Constraints: obs-6, obs-7
... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category S 1..* CodeableConcept Untersuchungskategorie
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... 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://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9269-2
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

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 1..1 code Symbol in syntax defined by the system
Fixed Value: 248241002
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:IEEE11073 Σ 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: urn:iso:std:iso:11073:10101
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... subject SΣ 1..1 Reference(Patient) Patient
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] SΣC 1..1 Quantity Untersuchungsergebnis
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... value 0..1 decimal Numerical value (with implicit precision)
.... comparator 0..1 code < | <= | >= | > - how to understand the value
.... unit 0..1 string Unit representation
.... system 1..1 uri System that defines coded unit form
Fixed Value: http://unitsofmeasure.org
.... code 1..1 code Coded form of the unit
Fixed Value: 1
.... value SΣ 0..1 decimal Wert
.... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... unit SΣ 0..1 string Einheit
.... system SΣC 0..1 uri CodeSystem aus dem die Einheit stammt
.... code SΣ 0..1 code Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... Slices for component SΣ 0..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... coding SΣ 0..* Coding Coding
..... Slices for value[x] SΣ 0..1 Wert der Komponente
Slice: Unordered, Open by type:$this
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
...... value[x]:valueCodeableConcept SΣ 0..1 CodeableConcept Kodiertes Ergebnis
....... coding SΣ 0..* Coding Coding
........ system SΣ 0..1 uri System
........ code SΣ 0..1 code Code
.... component:Eye SΣ 0..1 BackboneElement Augenöffnungsreflex
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9267-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Eye (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code
.... component:Motor SΣ 0..1 BackboneElement Motorische Reaktion
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9268-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Motor (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code
.... component:Verbal SΣ 0..1 BackboneElement Verbale Reaktion
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9270-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Verbal (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.category:survey Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.value[x].​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​value[x] Base required VS Score Glasgow Coma Score Eye 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Motor.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​value[x] Base required VS Score Glasgow Coma Score Motor 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Verbal.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​value[x] Base required VS Score Glasgow Coma Score Verbal 📦1.5.4 de.basisprofil.r4 v1.5

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation 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 Observation 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 Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation 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()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

This structure is derived from ScoreDE_GCS

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* ScoreDE_GCS Measurements and simple assertions
... 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
... status S 1..1 code Untersuchungsstatus
... Slices for category Content/Rules for all slices
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
... code S 1..1 CodeableConcept Code
.... coding S 1..* Coding Coding
.... Slices for coding Content/Rules for all slices
..... coding:loinc S 1..1 Coding LOINC Kodierung
..... coding:snomed S 0..* Coding SNOMED CT Kodierung
..... coding:IEEE11073 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: urn:iso:std:iso:11073:10101
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
... subject S 1..1 Reference(Patient) Patient
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 dateTime Datum und Uhrzeit der Untersuchung
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] S 1..1 Quantity Untersuchungsergebnis
.... value S 0..1 decimal Wert
.... unit S 0..1 string Einheit
.... system S 0..1 uri CodeSystem aus dem die Einheit stammt
.... code S 0..1 code Code der Einheit
... dataAbsentReason S 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
... method S 0..1 CodeableConcept Untersuchungsmethode
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... component S 0..* BackboneElement Vitalparameter-Komponente
.... code S 1..1 CodeableConcept Code
..... coding S 0..* Coding Coding
.... Slices for value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Komponente
Slice: Unordered, Open by type:$this
..... value[x]:valueCodeableConcept S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
... Slices for component Content/Rules for all slices
.... component:Eye S 0..1 BackboneElement Augenöffnungsreflex
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
.... component:Motor S 0..1 BackboneElement Motorische Reaktion
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
.... component:Verbal S 0..1 BackboneElement Verbale Reaktion
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* ScoreDE_GCS Measurements and simple assertions
Constraints: obs-6, obs-7
... 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
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code Untersuchungsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 1..* CodeableConcept Untersuchungskategorie
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... 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://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... 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 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9269-2
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

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 1..1 code Symbol in syntax defined by the system
Fixed Value: 248241002
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:IEEE11073 Σ 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: urn:iso:std:iso:11073:10101
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... 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
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] SΣC 1..1 Quantity Untersuchungsergebnis
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... value 0..1 decimal Numerical value (with implicit precision)
.... comparator 0..1 code < | <= | >= | > - how to understand the value
.... unit 0..1 string Unit representation
.... system 1..1 uri System that defines coded unit form
Fixed Value: http://unitsofmeasure.org
.... code 1..1 code Coded form of the unit
Fixed Value: 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
.... value SΣ 0..1 decimal Wert
.... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... unit SΣ 0..1 string Einheit
.... system SΣC 0..1 uri CodeSystem aus dem die Einheit stammt
.... code SΣ 0..1 code Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note 0..* Annotation Comments about the observation
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... referenceRange C 0..* BackboneElement Provides guide for interpretation
Constraints: obs-3
.... 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
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... Slices for component SΣ 0..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... Slices for value[x] SΣ 0..1 Wert der Komponente
Slice: Unordered, Open by type:$this
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
...... value[x]:valueCodeableConcept SΣ 0..1 CodeableConcept Kodiertes Ergebnis
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... coding SΣ 0..* Coding Coding
........ 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 0..1 uri System
........ version Σ 0..1 string Version of the system - if relevant
........ code SΣ 0..1 code 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
....... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Eye SΣ 0..1 BackboneElement Augenöffnungsreflex
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9267-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Eye (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Motor SΣ 0..1 BackboneElement Motorische Reaktion
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9268-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Motor (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Verbal SΣ 0..1 BackboneElement Verbale Reaktion
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9270-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Verbal (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.category:survey Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.value[x].​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📦4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​value[x] Base required VS Score Glasgow Coma Score Eye 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Eye.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Eye.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​value[x] Base required VS Score Glasgow Coma Score Motor 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Motor.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Motor.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​value[x] Base required VS Score Glasgow Coma Score Verbal 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Verbal.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Verbal.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation 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 Observation 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 Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation 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()
obs-3 error Observation.referenceRange Must have at least a low or a high or text low.exists() or high.exists() or text.exists()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)
ElementShort descriptionNotes
Observation.category Untersuchungskategorie

Motivation MS: Dieses Feld erlaubt die Sortierung und Abfrage anhand der Kategorie der Untersuchung
Observation.category:survey Untersuchungskategorie

Motivation MS: Dieses Feld erlaubt die Sortierung und Abfrage anhand der Kategorie der Untersuchung
Observation.code Code

Motivation MS: Die Observation wird anhand des Codes identifiziert.
Observation.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.code.coding:loinc LOINC Kodierung

Motivation MS: Kodierung des Vitalparameters mittels LOINC.
Observation.code.coding:snomed SNOMED CT Kodierung

Motivation MS: Kodierung des Vitalparameters mittels SNOMED CT.
Observation.component Vitalparameter-Komponente

Motivation MS: Erfassung der Komponenten eines Vitalparameters
Observation.component.code Code

Motivation MS: Die Komponente wird anhand des Codes identifiziert.
Observation.component.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.component.value[x] Wert der Komponente

Motivation MS: Der Wert der Komponente ist ein Ergebnis der Untersuchung
Observation.component.value[x]:valueCodeableConcept Kodiertes Ergebnis

Motivation MS: Kodierung der Ergebnisse der GCS-Komponenten.
Observation.component.value[x]:valueCodeableConcept.coding Coding

Motivation MS: Semantische Kodierung.
Observation.component.value[x]:valueCodeableConcept.coding.code Code

Motivation MS: Kodierter Wert aus einem CodeSystem.
Observation.component.value[x]:valueCodeableConcept.coding.system System

Motivation MS: URL des CodeSystems des kodierten Wertes.
Observation.component:Eye Augenöffnungsreflex

Motivation MS: Kodierung des Augenöffnungsreflexes.
Observation.component:Eye.code Code

Motivation MS: Die Komponente wird anhand des Codes identifiziert.
Observation.component:Eye.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.component:Eye.value[x] Kodiertes Ergebnis

Motivation MS: Kodierung der Ergebnisse der GCS-Komponenten.
Observation.component:Eye.value[x].coding Coding

Motivation MS: Semantische Kodierung.
Observation.component:Eye.value[x].coding.code Code

Motivation MS: Kodierter Wert aus einem CodeSystem.
Observation.component:Eye.value[x].coding.system System

Motivation MS: URL des CodeSystems des kodierten Wertes.
Observation.component:Motor Motorische Reaktion

Motivation MS: Kodierung der motorischen Reaktion.
Observation.component:Motor.code Code

Motivation MS: Die Komponente wird anhand des Codes identifiziert.
Observation.component:Motor.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.component:Motor.value[x] Kodiertes Ergebnis

Motivation MS: Kodierung der Ergebnisse der GCS-Komponenten.
Observation.component:Motor.value[x].coding Coding

Motivation MS: Semantische Kodierung.
Observation.component:Motor.value[x].coding.code Code

Motivation MS: Kodierter Wert aus einem CodeSystem.
Observation.component:Motor.value[x].coding.system System

Motivation MS: URL des CodeSystems des kodierten Wertes.
Observation.component:Verbal Verbale Reaktion

Motivation MS: Kodierung der verbalen Reaktion.
Observation.component:Verbal.code Code

Motivation MS: Die Komponente wird anhand des Codes identifiziert.
Observation.component:Verbal.code.coding Coding

Motivation MS: Semantische Kodierung
Observation.component:Verbal.value[x] Kodiertes Ergebnis

Motivation MS: Kodierung der Ergebnisse der GCS-Komponenten.
Observation.component:Verbal.value[x].coding Coding

Motivation MS: Semantische Kodierung.
Observation.component:Verbal.value[x].coding.code Code

Motivation MS: Kodierter Wert aus einem CodeSystem.
Observation.component:Verbal.value[x].coding.system System

Motivation MS: URL des CodeSystems des kodierten Wertes.
Observation.dataAbsentReason Grund für fehlende Untersuchungsergebnisse

Motivation MS: Dieses Feld erlaubt die Angabe von Gründen für fehlende Untersuchungsergebnisse
Observation.device Gerät

Einschränkung der übergreifenden MS-Definition:
Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Geräts, mittels dessen der Parameter erhoben worden ist, so MUSS dieses System die Information NICHT abbilden.

Motivation zum eingeschränkten MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit. Allerdings rechtfertigt der Stand der Umsetzung in gängigen Systemen eine Implementierungspflicht (MS) für die Schnittstelle nicht.
Observation.effective[x] Datum und Uhrzeit der Untersuchung

Motivation MS: Das Datum und die Uhrzeit der Untersuchung sind für die Interpretation der Untersuchungsergebnisse relevant
Observation.encounter Aufenthaltsbezug

Motivation MS: Der Behandlungskontext ist für die Interpretation der Untersuchungsergebnisse relevant
Observation.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.
Observation.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.
Observation.method Untersuchungsmethode

Einschränkung der übergreifenden MS-Definition:
Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung der Untersuchungsmethode, so MUSS dieses System die Information NICHT abbilden

Motivation zum eingeschränkten MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit. Allerdings rechtfertigt der Stand der Umsetzung in gängigen Systemen eine Implementierungspflicht (MS) für die Schnittstelle nicht.
Observation.performer Untersuchender

Motivation MS: Dieses Feld stellt präzisierende Angaben zum Zweck der Qualitätsbewertung bereit
Observation.status Untersuchungsstatus

WICHTIGER Hinweis für Implementierer:

  • Alle server-seitigen Implementierungen MÜSSEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens jedoch final.
  • Alle client-seitigen Implementierungen MÜSSEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können, beispielsweise durch Ausblenden/Durchstreichen von Ressourcen mit dem status entered-in-error und Ausgrauen von Ressourcen, die einen Plan- oder Entwurfs-Status haben.
Observation.subject Patient

Motivation 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.
Observation.value[x] Untersuchungsergebnis

Motivation MS: Der Wert des Vitalparameters ist das zentrale Ergebnis der Untersuchung
Observation.value[x].code Code der Einheit

Motivation MS: Eine Quantity soll einen Code der die Einheit kodiert enthalten
Observation.value[x].system CodeSystem aus dem die Einheit stammt

Motivation MS: Eine Quantity soll ein System, mit dem die Einheit kodiert wird, enthalten
Observation.value[x].unit Einheit

Motivation MS: Eine Quantity soll eine Einheit enthalten
Observation.value[x].value Wert

Motivation MS: Eine Quantity soll einen Wert enthalten

This structure is derived from ScoreDE_GCS

Summary

Mandatory: 0 element(1 nested mandatory element)
Must-Support: 50 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.component.value[x]

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* ScoreDE_GCS Measurements and simple assertions
Constraints: obs-6, obs-7
... 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category S 1..* CodeableConcept Untersuchungskategorie
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... 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://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... Slices for coding SΣ 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9269-2
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

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 1..1 code Symbol in syntax defined by the system
Fixed Value: 248241002
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:IEEE11073 Σ 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: urn:iso:std:iso:11073:10101
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
... subject SΣ 1..1 Reference(Patient) Patient
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] SΣC 1..1 Quantity Untersuchungsergebnis
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... value 0..1 decimal Numerical value (with implicit precision)
.... comparator 0..1 code < | <= | >= | > - how to understand the value
.... unit 0..1 string Unit representation
.... system 1..1 uri System that defines coded unit form
Fixed Value: http://unitsofmeasure.org
.... code 1..1 code Coded form of the unit
Fixed Value: 1
.... value SΣ 0..1 decimal Wert
.... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... unit SΣ 0..1 string Einheit
.... system SΣC 0..1 uri CodeSystem aus dem die Einheit stammt
.... code SΣ 0..1 code Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... Slices for component SΣ 0..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... coding SΣ 0..* Coding Coding
..... Slices for value[x] SΣ 0..1 Wert der Komponente
Slice: Unordered, Open by type:$this
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
...... value[x]:valueCodeableConcept SΣ 0..1 CodeableConcept Kodiertes Ergebnis
....... coding SΣ 0..* Coding Coding
........ system SΣ 0..1 uri System
........ code SΣ 0..1 code Code
.... component:Eye SΣ 0..1 BackboneElement Augenöffnungsreflex
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9267-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Eye (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code
.... component:Motor SΣ 0..1 BackboneElement Motorische Reaktion
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9268-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Motor (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code
.... component:Verbal SΣ 0..1 BackboneElement Verbale Reaktion
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9270-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... coding SΣ 0..* Coding Coding
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Verbal (required)
...... coding SΣ 0..* Coding Coding
....... system SΣ 0..1 uri System
....... code SΣ 0..1 code Code

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.category:survey Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.value[x].​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​value[x] Base required VS Score Glasgow Coma Score Eye 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Motor.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​value[x] Base required VS Score Glasgow Coma Score Motor 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Verbal.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​value[x] Base required VS Score Glasgow Coma Score Verbal 📦1.5.4 de.basisprofil.r4 v1.5

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation 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 Observation 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 Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation 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()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

Differential View

This structure is derived from ScoreDE_GCS

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation 0..* ScoreDE_GCS Measurements and simple assertions
... 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
... status S 1..1 code Untersuchungsstatus
... Slices for category Content/Rules for all slices
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
... code S 1..1 CodeableConcept Code
.... coding S 1..* Coding Coding
.... Slices for coding Content/Rules for all slices
..... coding:loinc S 1..1 Coding LOINC Kodierung
..... coding:snomed S 0..* Coding SNOMED CT Kodierung
..... coding:IEEE11073 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: urn:iso:std:iso:11073:10101
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
... subject S 1..1 Reference(Patient) Patient
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... effective[x] S 1..1 dateTime Datum und Uhrzeit der Untersuchung
... performer S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] S 1..1 Quantity Untersuchungsergebnis
.... value S 0..1 decimal Wert
.... unit S 0..1 string Einheit
.... system S 0..1 uri CodeSystem aus dem die Einheit stammt
.... code S 0..1 code Code der Einheit
... dataAbsentReason S 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
... method S 0..1 CodeableConcept Untersuchungsmethode
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... component S 0..* BackboneElement Vitalparameter-Komponente
.... code S 1..1 CodeableConcept Code
..... coding S 0..* Coding Coding
.... Slices for value[x] S 0..1 Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period Wert der Komponente
Slice: Unordered, Open by type:$this
..... value[x]:valueCodeableConcept S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
... Slices for component Content/Rules for all slices
.... component:Eye S 0..1 BackboneElement Augenöffnungsreflex
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
.... component:Motor S 0..1 BackboneElement Motorische Reaktion
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code
.... component:Verbal S 0..1 BackboneElement Verbale Reaktion
..... code S 1..1 CodeableConcept Code
...... coding S 0..* Coding Coding
..... value[x] S 0..1 CodeableConcept Kodiertes Ergebnis
...... coding S 0..* Coding Coding
....... system S 0..1 uri System
....... code S 0..1 code Code

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Observation C 0..* ScoreDE_GCS Measurements and simple assertions
Constraints: obs-6, obs-7
... 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
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding
... 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
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business Identifier for observation
... basedOn Σ 0..* Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) Fulfills plan, proposal or order
... partOf Σ 0..* Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) Part of referenced event
... status ?!SΣ 1..1 code Untersuchungsstatus
Binding: ObservationStatus (required): Codes providing the status of an observation.
... Slices for category S 1..* CodeableConcept Untersuchungskategorie
Slice: Unordered, Open by pattern:$this
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
.... category:survey S 1..1 CodeableConcept Untersuchungskategorie
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... 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://terminology.hl7.org/CodeSystem/observation-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: survey
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
.... 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 1..* Coding Coding
Slice: Unordered, Open by pattern:$this
..... coding:loinc SΣ 1..1 Coding LOINC Kodierung

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://loinc.org
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9269-2
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:snomed SΣ 0..* Coding SNOMED CT Kodierung

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 1..1 code Symbol in syntax defined by the system
Fixed Value: 248241002
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... coding:IEEE11073 Σ 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: urn:iso:std:iso:11073:10101
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 153728
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Patient
... focus Σ 0..* Reference(Resource) What the observation is about, when it is not about the subject of record
... 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
... effective[x] SΣC 1..1 dateTime Datum und Uhrzeit der Untersuchung
Constraints: vs-de-1
... issued Σ 0..1 instant Date/Time this version was made available
... performer SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) Untersuchender
... value[x] SΣC 1..1 Quantity Untersuchungsergebnis
Required Pattern: At least the following
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... value 0..1 decimal Numerical value (with implicit precision)
.... comparator 0..1 code < | <= | >= | > - how to understand the value
.... unit 0..1 string Unit representation
.... system 1..1 uri System that defines coded unit form
Fixed Value: http://unitsofmeasure.org
.... code 1..1 code Coded form of the unit
Fixed Value: 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
.... value SΣ 0..1 decimal Wert
.... comparator ?!Σ 0..1 code < | <= | >= | > - how to understand the value
Binding: QuantityComparator (required): How the Quantity should be understood and represented.
.... unit SΣ 0..1 string Einheit
.... system SΣC 0..1 uri CodeSystem aus dem die Einheit stammt
.... code SΣ 0..1 code Code der Einheit
... dataAbsentReason SC 0..1 CodeableConcept Grund für fehlende Untersuchungsergebnisse
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
... note 0..* Annotation Comments about the observation
... method S 0..1 CodeableConcept Untersuchungsmethode
Binding: ObservationMethods (example): Methods for simple observations.
... device S 0..1 Reference(Device | DeviceMetric) Gerät
... referenceRange C 0..* BackboneElement Provides guide for interpretation
Constraints: obs-3
.... 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
.... low C 0..1 SimpleQuantity Low Range, if relevant
.... high C 0..1 SimpleQuantity High Range, if relevant
.... type 0..1 CodeableConcept Reference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
.... appliesTo 0..* CodeableConcept Reference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
.... age 0..1 Range Applicable age range, if relevant
.... text 0..1 string Text based reference range in an observation
... hasMember Σ 0..* Reference(Observation | QuestionnaireResponse | MolecularSequence) Related resource that belongs to the Observation group
... derivedFrom Σ 0..* Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) Related measurements the observation is made from
... Slices for component SΣ 0..* BackboneElement Vitalparameter-Komponente
Slice: Unordered, Open by pattern:code
.... component:All Slices Content/Rules for all slices
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... Slices for value[x] SΣ 0..1 Wert der Komponente
Slice: Unordered, Open by type:$this
...... valueQuantity Quantity
...... valueCodeableConcept CodeableConcept
...... valueString string
...... valueBoolean boolean
...... valueInteger integer
...... valueRange Range
...... valueRatio Ratio
...... valueSampledData SampledData
...... valueTime time
...... valueDateTime dateTime
...... valuePeriod Period
...... value[x]:valueCodeableConcept SΣ 0..1 CodeableConcept Kodiertes Ergebnis
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
....... coding SΣ 0..* Coding Coding
........ 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 0..1 uri System
........ version Σ 0..1 string Version of the system - if relevant
........ code SΣ 0..1 code 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
....... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Eye SΣ 0..1 BackboneElement Augenöffnungsreflex
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9267-6
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Eye (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Motor SΣ 0..1 BackboneElement Motorische Reaktion
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9268-4
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Motor (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result
.... component:Verbal SΣ 0..1 BackboneElement Verbale Reaktion
..... 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 SΣ 1..1 CodeableConcept Code
Binding: LOINCCodes (example): Codes identifying names of simple observations.
Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
....... 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://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 9270-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text 0..1 string Plain text representation of the concept
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
...... text Σ 0..1 string Plain text representation of the concept
..... value[x] SΣ 0..1 CodeableConcept Kodiertes Ergebnis
Binding: VS Score Glasgow Coma Score Verbal (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... coding SΣ 0..* Coding Coding
....... 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 0..1 uri System
....... version Σ 0..1 string Version of the system - if relevant
....... code SΣ 0..1 code 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
...... text Σ 0..1 string Plain text representation of the concept
..... dataAbsentReason C 0..1 CodeableConcept Why the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
..... interpretation 0..* CodeableConcept High, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
..... referenceRange 0..* See referenceRange (Observation) Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Observation.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Observation.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Observation.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Observation.status Base required ObservationStatus 📍4.0.1 FHIR Std.
Observation.category Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.category:survey Base preferred Observation Category Codes 📦4.0.1 FHIR Std.
Observation.code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Observation.value[x].​comparator Base required QuantityComparator 📍4.0.1 FHIR Std.
Observation.dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.method Base example Observation Methods 📦4.0.1 FHIR Std.
Observation.referenceRange.​type Base preferred Observation Reference Range Meaning Codes 📦4.0.1 FHIR Std.
Observation.referenceRange.​appliesTo Base example Observation Reference Range Applies To Codes 📦4.0.1 FHIR Std.
Observation.component.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Eye.​value[x] Base required VS Score Glasgow Coma Score Eye 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Eye.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Eye.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Motor.​value[x] Base required VS Score Glasgow Coma Score Motor 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Motor.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Motor.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​code Base example LOINC Codes 📦4.0.1 FHIR Std.
Observation.component:Verbal.​value[x] Base required VS Score Glasgow Coma Score Verbal 📦1.5.4 de.basisprofil.r4 v1.5
Observation.component:Verbal.​dataAbsentReason Base extensible DataAbsentReason 📦4.0.1 FHIR Std.
Observation.component:Verbal.​interpretation Base extensible Observation Interpretation Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Observation If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Observation 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 Observation 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 Observation If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Observation 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()
obs-3 error Observation.referenceRange Must have at least a low or a high or text low.exists() or high.exists() or text.exists()
obs-6 error Observation dataAbsentReason SHALL only be present if Observation.value[x] is not present dataAbsentReason.empty() or value.empty()
obs-7 error Observation If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()
vs-de-1 error Observation.effective[x] If Observation.effective[x] has a value then that value shall be precise to the day (($this is dateTime) implies ($this as dateTime).toString().length() >= 10) and ($this.start.exists() implies ($this.start as dateTime).toString().length() >= 10) and ($this.end.exists() implies ($this.end as dateTime).toString().length() >= 10)

This structure is derived from ScoreDE_GCS

Summary

Mandatory: 0 element(1 nested mandatory element)
Must-Support: 50 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Observation.component.value[x]

 

Other representations of profile: CSV, Excel, Schematron