Chronic neurological or mental diseases


Parameter Case Report Form and Response Options

Does the patient suffer from a chronic neurological disease or psychiatric illness? Yes No Unknown
Parkinson's disease
Dementia
Multiple sclerosis
Combined disorder of muscle and peripheral nerve
Epilepsy
Migraine
History of a cerebrovascular accident with residual deficit
History of a cerebrovascular accident without residual deficits
Psychotic disorder
Depressive disorder
Anxiety disorder

This is an example of how the case report form could look like when such a data collection tool is used.


To integrate data from clinical care and research such as clinical trials, the guide relies on FHIR resources for data-exchange from the clinical and diagnostic healthcare process rather than constructing a plain questionnaire.

This profile of a FHIR Condition is derived from the Diagnosis-profile of the Medical Informatics Initiative (MII). The valueset bindings on the Condition.code element have been constrained to solely feature the response options for this particular parameter of the case report form. For the explicitly listed diseases in the case report form, the SNOMED and ICD codes are also explicitly specified in the ValueSets below. Note that for the 'Other' option the ValueSets contain filters that allow a number of other codes for this category that are included in the expansion.

A separate instance of a Condition resource is created for each of the requested diseases.

To represent the presence, absence or uncertainty of findings, use Condition.verificationStatus or uncertaintyOfPresence on Condition.modifierExtension. This is used to map the Yes/No/Unknown scheme from case report forms to the Condition resource. Note the additional constraint on Condition that checks if either verificationStatus or the extension is present:

keyseverityhumanexpression
unk-1errorIf verificationStatus is present, uncertaintyOfPresence-Extension SHALL NOT be present.verificationStatus.exists() != Condition.modifierExtension.where(url = 'https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence').exists()

Profile - Chronic Neurological or Mental Diseases

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/chronic-neurological-mental-diseases

Snapshot

ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
uncertaintyOfPresenceS ?! I0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemΣ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
severity0..1CodeableConceptBinding
Mehrfachcodierungs-KennzeichenS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
DiagnosesicherheitS I0..1Extension(Coding)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ I1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
lebensphase-vonS I0..1Extension(CodeableConcept)
lebensphase-bisS I0..1Extension(CodeableConcept)
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Extension - Uncertainty of Presence

Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence

Snapshot

extensionI0..0Extension
url1..1System.StringFixed Value
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string


ValueSets

Valuesets are provided with both SNOMED-CT and ICD-10-GM codes.


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/chronic-neurological-mental-diseases

ValueSet 'ChronicNeurologicalMentalDiseases'

Version1.0.6
Published byBerlin Institute of Health at Charité (BIH)
StatusActive
ExperimentalFalse

Chronic neurological or mental diseases in the context of Covid-19

Contact Information

Website: https://www.bihealth.org/en/re...

This value set includes codes from the following code systems:

  • The following codes from system: SNOMED_CT

    CodeDisplay
    128283000Chronic nervous system disorder (disorder)
    74732009Mental disorder (disorder)
    197480006Anxiety disorder (disorder)
    35489007Depressive disorder (disorder)
    69322001Psychotic disorder (disorder)
    49049000Parkinson's disease (disorder)
    52448006Dementia (disorder)
    24700007Multiple sclerosis (disorder)
    257277002Combined disorder of muscle AND peripheral nerve (disorder)
    84757009Epilepsy (disorder)
    37796009Migraine (disorder)
    440140008History of cerebrovascular accident with residual deficit (situation)
    429993008History of cerebrovascular accident without residual deficits (situation)
  • Include codes from SNOMED_CT where concept IsA 128283000
  • Include codes from SNOMED_CT where concept IsA 74732009
  • Include codes from SNOMED_CT where concept IsA 49049000
  • Include codes from SNOMED_CT where concept IsA 24700007
  • Include codes from SNOMED_CT where concept IsA 257277002
  • Include codes from SNOMED_CT where concept IsA 84757009
  • Include codes from SNOMED_CT where concept IsA 37796009
  • Include codes from SNOMED_CT where concept IsA 440140008
  • Include codes from SNOMED_CT where concept IsA 429993008


Canonical: https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/chronic-neurological-mental-diseases-icd

ValueSet 'ChronicNeurologicalMentalDiseasesICD'

Version1.0.6
Published byBerlin Institute of Health at Charité (BIH)
StatusActive
ExperimentalFalse

Chronic neurological or mental diseases in the context of Covid-19 from ICD-10-GM

Contact Information

Website: https://www.bihealth.org/en/re...

This value set includes codes from the following code systems:

  • The following codes from system: ICD10GM

    CodeDisplay
    F99Psychische Störung ohne nähere Angabe
    G20Primäres Parkinson-Syndrom
    G35Multiple Sklerose [Encephalomyelitis disseminata]
    G96.9Krankheit des Zentralnervensystems, nicht näher bezeichnet
    F41.9Angststörung, nicht näher bezeichnet
    F32.9Depressive Episode, nicht näher bezeichnet
    F29Nicht näher bezeichnete nichtorganische Psychose
    F03Nicht näher bezeichnete Demenz
    G70.9Neuromuskuläre Krankheit, nicht näher bezeichnet
    G40.9Epilepsie, nicht näher bezeichnet
    G43.9Migräne, nicht näher bezeichnet
    I69.4Folgen eines Schlaganfalls, nicht als Blutung oder Infarkt bezeichnet
    Z86.7Krankheiten des Kreislaufsystems in der Eigenanamnese
  • Include codes from ICD10GM where concept DescendentOf G20Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf G35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F23Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F28Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F29Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F00Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F01Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F02Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G70Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G71Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G72Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G73Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G43Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf I69Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf G20Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf G35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F23Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F28Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F29Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F00Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F01Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F02Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G70Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G71Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G72Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G73Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G43Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf I69Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf G20Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf G35Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F32Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F33Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf F23Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F28Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F29Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F00Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F01Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA F02Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G70Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G71Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G72Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G73Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G40Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G41Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept IsA G43Include codes from ICD10GM where child Exists false
  • Include codes from ICD10GM where concept DescendentOf I69Include codes from ICD10GM where child Exists false


Examples

Chronic Neurological or Mental Disease present
Example condition that is confirmed present

{
    "resourceType": "Condition",
    "id": "chronic-neurological-mental-disease-present",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/chronic-neurological-mental-diseases"
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed",
                "display": "Confirmed"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410605003",
                "display": "Confirmed present (qualifier value)"
            }
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "code": "active",
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "display": "Active"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "394591006",
                    "system": "http://snomed.info/sct",
                    "display": "Neurology"
                },
                {
                    "code": "394587001",
                    "system": "http://snomed.info/sct",
                    "display": "Psychiatry"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "74732009",
                "system": "http://snomed.info/sct",
                "display": "Mental disorder"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}


Chronic Neurological or Mental Disease absent
Example condition that is confirmed absent

{
    "resourceType": "Condition",
    "id": "chronic-neurological-mental-disease-ho-cer-vas-acc-absent",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/chronic-neurological-mental-diseases"
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "refuted",
                "display": "Refuted"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "410594000",
                "display": "Definitely NOT present (qualifier value)"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "394591006",
                    "system": "http://snomed.info/sct",
                    "display": "Neurology"
                },
                {
                    "code": "394587001",
                    "system": "http://snomed.info/sct",
                    "display": "Psychiatry"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "440140008",
                "system": "http://snomed.info/sct",
                "display": "History of cerebrovascular accident with residual deficit"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}


Chronic Neurological or Mental Disease unknown
Example condition where the presence is unknown

{
    "resourceType": "Condition",
    "id": "chronic-neurological-mental-disease-muscle-and-nerve-unknown",
    "meta": {
        "profile":  [
            "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/chronic-neurological-mental-diseases"
        ]
    },
    "modifierExtension":  [
        {
            "url": "https://www.netzwerk-universitaetsmedizin.de/fhir/StructureDefinition/uncertainty-of-presence",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://snomed.info/sct",
                        "code": "261665006",
                        "display": "Unknown (qualifier value)"
                    }
                ],
                "text": "Presence of condition is unknown."
            }
        }
    ],
    "category":  [
        {
            "coding":  [
                {
                    "code": "394591006",
                    "system": "http://snomed.info/sct",
                    "display": "Neurology"
                },
                {
                    "code": "394587001",
                    "system": "http://snomed.info/sct",
                    "display": "Psychiatry"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "257277002",
                "system": "http://snomed.info/sct",
                "display": "Combined disorder of muscle AND peripheral nerve"
            }
        ]
    },
    "subject": {
        "reference": "Patient/gecco-patient"
    },
    "recordedDate": "2020-10-06"
}