HiGHmed

HiGHmed - Infection Control - ImplementationGuide

Diagnose - Condition


Bestehende Profile Kerndatensatz Medizininformatik-Initiative

Durch den Kerndatensatz der Medizininformatik Initative wird bereits das Konzept der "Diagnose" im Modul Diagnose definiert. Diese Spezifikation wird im Rahmen dieses Moduls wiederverwendet.

Siehe Profil "Condition - Diagnose".

Canonical URL: https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose

Es ist zu beachten, dass alle weiteren Vorgaben und Pflichtfelder des Kerndatensatz Moduls einzuhalten sind. Weitere Informationen finden sich im Abschnitt des ImplementationGuides - Modul Diagnose.


Abbildung Diagnose - HiGHmed Use Case Infection Control


Beschreibung

Das vorliegende abgeleitete Profil beschreibt den Patient im HiGHmed Projekt, Infection Control.

NameCanonical
Profile_HiGHmed_InfectionControl_Diagnosehttp://highmed.org/fhir/StructureDefinition/ic/Condition

Differential

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
verificationStatusΣ ?! I0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
DiagnosesicherheitS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
AusrufezeichenCodeS I0..*Extension(Coding-Profil für ICD-10-GM)
ManifestationsCodeS I0..*Extension(Coding-Profil für ICD-10-GM)
PrimaercodeS I0..*Extension(Coding-Profil für ICD-10-GM)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
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)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Mapping

Alle Elemente für das Konzept Diagnose des Use Case - Infection Control lassen sich durch das Profil wie folgt abbilden:

Logischer Datensatz FHIR Element
Diagnose.Bericht ID Abbildung siehe "Mikrobiologischen Befund - DiagnosticReport"
Diagnose.Fall-Kennung Abbildung siehe "Fall - Encounter"
Diagnose.DiagnoseKodiert Condition.code
Diagnose.Freitextbeschreibung Condition.code.text
Diagnose.KlinischrelevanterZeitraum (Zeitpunkt des Auftretens) Condition.onset[x]:onsetDateTime
Diagnose.Feststellungsdatum Condition.recordedDate
Diagnose.Klinischer Status Condition.clinicalStatus
Diagnose.Körperstelle Condition.bodySite
Diagnose.Seitenlokalisation Condition.code:icd10-gm.extension:Seitenlokalisation
Diagnose.Lebensphase Beginn Condition.onset[x]:onsetPeriod.start.extension:lebensphase-start
Diagnose.Lebensphase Ende Condition.onset[x]:onsetPeriod.start.extension:lebensphase-ende
Diagnose.Datum/Zeitpunkt der Genesung Condition.abatement[x]
Diagnose.Diagnostische Sicherheit Condition.code:icd10-gm.extension:Diagnosesicherheit
Diagnose.Diagnoseerläuterung Condition.note
Diagnose.LetztesDokumentationsdatum Abbildung siehe "Letztes Dokumentationsdatum - Provenance"

Snapshot

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
verificationStatusΣ ?! I0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
DiagnosesicherheitS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
AusrufezeichenCodeS I0..*Extension(Coding-Profil für ICD-10-GM)
ManifestationsCodeS I0..*Extension(Coding-Profil für ICD-10-GM)
PrimaercodeS I0..*Extension(Coding-Profil für ICD-10-GM)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
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)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Beispiele

{
    "resourceType": "Condition",
    "id": "ExampleHiGHmedInfectionControlCondition",
    "meta": {
        "profile":  [
            "http://highmed.org/fhir/StructureDefinition/ic/Condition"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "resolved"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2022",
                "code": "B34.9",
                "display": "Virusinfektion, nicht näher bezeichnet"
            }
        ]
    },
    "subject": {
        "reference": "Patient/ExampleHiGHmedInfectionControlPatient"
    },
    "recordedDate": "2021-05-16T08:49:21+02:00",
    "abatementDateTime": "2021-05-25"
}