HiGHmed - Infection Control - ImplementationGuide

Probendetails - Specimen

Bestehende Profile Kerndatensatz Medizininformatik-Initiative

Modul Labor

Durch den Kerndatensatz der Medizininformatik Initative wird bereits das Konzept der "Probe" im Modul Labor definiert. Jedoch wurde im Kerndatensatz-Modul kein FHIR Profil für dieses Konzept erstell. Gründe hierfür siehe: https://simplifier.net/guide/LaborbefundinderMedizininformatik-Initiative/Specimen

Modul Biobank

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

Siehe Profil "Profile - Specimen - Bioprobe - Core".

Canonical URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/StructureDefinition/SpecimenCore

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

Abbildung Probe - HiGHmed Use Case Infection Control

Beschreibung

Dieses Profil beschreibt die Probe im HiGHmed Projekt, Infection Control.

Im HiGHmed Infection Control Use Case, Probentypen sind mit SNOMED CT spezifiziert.

Zum Beispiel für Mikrobiologischer Befund:

Blood specimen in blood culture bottle (specimen)
Blood specimen in aerobic blood culture bottle (specimen)
Blood specimen in anaerobic blood culture bottle (specimen)
Swab (specimen)

Zum Beispiel für Virologischer Befund:

Swab (specimen)
Sputum specimen (specimen)
Saliva specimen (specimen)
Respiratory fluid specimen (specimen)
Bronchoalveolar lavage fluid sample (specimen)

Eine Probe kann mehrere Isolate enthalten. Das Isolat ist über specimen.parent mit der Probe verbunden. Isolatnummer und Analyseergebnis-Reihenfolge werden in Isolat als Specimen.accessionIdentifier spezifiziert.

Name	Canonical
Profile_HiGHmed_InfectionControl_Specimen	http://highmed.org/fhir/StructureDefinition/ic/Specimen

Differential

Profile_HiGHmed_InfectionControl_Specimen (Specimen)	I		Specimen	Element id Specimen Short description Sample for analysis Alternate names Probe Definition Eine physikalische Probe zur Erforschung, Untersuchung oder Analyse, die von einer Person entnommen wurde oder die sich auf die Person bezieht. Data type Specimen Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act rim: Role[classCode=SPEC]
id	Σ	0..1	string	There are no (further) constraints on this element Element id Specimen.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id Specimen.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Specimen.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id Specimen.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id Specimen.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Specimen.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	S Σ	0..*	Identifier	Element id Specimen.identifier Short description External Identifier Definition Eine eindeutige Kennung der Probe, die von einer Organisation außerhalb des Labors wie dem Auftraggeber zugeordnet wurde. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.identifier v2: SPM-2 rim: .id v2: OBR-2.1
accessionIdentifier	S Σ	1..1	Identifier	Element id Specimen.accessionIdentifier Short description Eine eindeutige Kennung der Probe, die normalerweise vom Labor vergeben wird. Definition The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.identifier v2: SPM-30 (v2.7+) rim: .participation[typeCode=SBJ].act[classCode=ACSN, moodCode=EVN].id v2: OBR-3.1
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id Specimen.status Short description available \| unavailable \| unsatisfactory \| entered-in-error Definition The availability of the specimen. Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding Codes providing the status/availability of a specimen. SpecimenStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.status v2: SPM-20 rim: status
type	S Σ I	1..1	CodeableConceptBinding	Element id Specimen.type Short description Kind of material that forms the specimen Definition The kind of material that forms the specimen. Comments The type can change the way that a specimen is handled and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems. Data type CodeableConcept Binding Use Case IC Probenart VS_Highmed_Probenart_Mikrobiologischer_Befund_SNOMEDCT (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Highmed-IC-Specimen-1: Falls ein Isolat kodiert wird, muss die Probe auch angeben werden `coding.where(code = '429951000124103' and system = 'http://snomed.info/sct').exists() implies %resource.parent.exists()` Mappings w5: FiveWs.what[x] v2: SPM-4 and possibly SPM-5 rim: .code v2: OBR-15
subject	S Σ	1..1	Reference(Patient \| Group \| Device \| Substance \| Location)	There are no (further) constraints on this element Element id Specimen.subject Short description Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device Definition Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. Requirements Must know the subject context. Data type Reference(Patient \| Group \| Device \| Substance \| Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] rim: .scoper or .scoper.playsRole w5: FiveWs.subject
receivedTime	S Σ	0..1	dateTime	Element id Specimen.receivedTime Short description Datum und Uhrzeit des Eingangs der Probe im Labor. Definition Time when specimen was received for processing or testing. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.done[x] v2: SPM-18 rim: .participation[typeCode=SBJ].act[code=SPCREC, moodCode=EVN].effectiveTime v2: OBR-14
parent	S	0..1	Reference(Profile_HiGHmed_InfectionControl_Specimen)	Element id Specimen.parent Short description Specimen from which this specimen originated Definition Eindeutige Kennung der verwandten Probe(n), bei der die Probe in Teilproben aufgeteilt ist. Comments The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample. Data type Reference(Profile_HiGHmed_InfectionControl_Specimen) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .scoper (if parent) .player.scopesRole[classCode=SPEC].player (if child) v2: OBR-29
request		0..*	Reference(ServiceRequest)	There are no (further) constraints on this element Element id Specimen.request Short description Why the specimen was collected Definition Details concerning a service request that required a specimen to be collected. Comments The request may be explicit or implied such with a ServiceRequest that requires a blood draw. Data type Reference(ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.why[x] v2: ORC? OBR-2/3? rim: outboundRelationship[typeCode=FLFS].target
collection	S	1..1	BackboneElement	There are no (further) constraints on this element Element id Specimen.collection Short description Collection details Definition Details concerning the specimen collection. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-14 rim: .participation[typeCode=SBJ].act[classCode=SPECCOLLECT, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Specimen.collection.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.collection.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.collection.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
collector	S Σ	0..1	Reference(Practitioner \| PractitionerRole)	Element id Specimen.collection.collector Short description Die Person oder Organisation die für die Entnahme der Probe verantwortlich war. Definition Person who collected the specimen. Data type Reference(Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.actor v2: PRT rim: .participation[typeCode=PFM].role v2: OBR-10
collected[x]	S Σ I	1..1		Element id Specimen.collection.collected[x] Short description Collection time Definition Das Datum und die Uhrzeit, zu der die Probennahme angeordnet wurde oder stattfand. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.init v2: SPM-17 rim: .effectiveTime v2: OBR-7
collectedDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
collectedPeriod			Period	There are no (further) constraints on this element Data type Period
duration	Σ	0..1	Duration	There are no (further) constraints on this element Element id Specimen.collection.duration Short description How long it took to collect specimen Definition The span of time over which the collection of a specimen occurred. Data type Duration Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.init
quantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.collection.quantity Short description The quantity of specimen collected Definition The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-12 rim: .participation[typeCode=SBJ].role[classCode=SPEC].player.quantity
method		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.collection.method Short description Technique used to perform collection Definition A coded value specifying the technique that is used to perform the procedure. Data type CodeableConcept Binding The technique that is used to perform the procedure. FHIRSpecimenCollectionMethod (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-7 rim: .methodCode
bodySite	S	1..1	CodeableConceptBinding	Element id Specimen.collection.bodySite Short description Anatomical collection site Definition Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens. Comments If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension bodySite. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. VS_Highmed_Probenentnahmestelle_Mikrobiologischer_Befund_SNOMEDCT (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-8 and SPM-9 rim: .targetSiteCode v2: OBR-15.4,OBR-15.5
fastingStatus[x]	Σ	0..1	Binding	There are no (further) constraints on this element Element id Specimen.collection.fastingStatus[x] Short description Whether or how long patient abstained from food and/or drink Definition Abstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Requirements Many diagnostic tests require fasting to facilitate accurate interpretation. Comments Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation `such as`Observation.component code` = LOINC 49541-6 (Fasting status - Reported). Binding Codes describing the fasting status of the patient. v2.0916 (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBR-
fastingStatusCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
fastingStatusDuration			Duration	There are no (further) constraints on this element Data type Duration
processing		0..*	BackboneElement	There are no (further) constraints on this element Element id Specimen.processing Short description Processing and processing step details Definition Details concerning processing and processing steps for the specimen. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .participation[typeCode=SBJ].act[code=SPCTRT, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Specimen.processing.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.processing.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.processing.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
description		0..1	string	There are no (further) constraints on this element Element id Specimen.processing.description Short description Textual description of procedure Definition Textual description of procedure. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .text
procedure		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.processing.procedure Short description Indicates the treatment step applied to the specimen Definition A coded value specifying the procedure used to process the specimen. Data type CodeableConcept Binding Type indicating the technique used to process the specimen. SpecimenProcessingProcedure (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .code
additive		0..*	Reference(Substance)	There are no (further) constraints on this element Element id Specimen.processing.additive Short description Material used in the processing step Definition Material used in the processing step. Data type Reference(Substance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-6 rim: .participation[typeCode=CSM].role[classCode=ADTV].code
time[x]		0..1		There are no (further) constraints on this element Element id Specimen.processing.time[x] Short description Date and time of specimen processing Definition A record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .effectiveTime
timeDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
timePeriod			Period	There are no (further) constraints on this element Data type Period
container		0..*	BackboneElement	There are no (further) constraints on this element Element id Specimen.container Short description Direct container of specimen (tube/slide, etc.) Definition The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .player.scopingRole[classCode=CONT].scoper
id		0..1	string	There are no (further) constraints on this element Element id Specimen.container.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.container.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.container.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Specimen.container.identifier Short description Id for the container Definition Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-3 rim: .id
description		0..1	string	There are no (further) constraints on this element Element id Specimen.container.description Short description Textual description of the container Definition Textual description of the container. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .desc
type		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.container.type Short description Kind of container directly associated with specimen Definition The type of container associated with the specimen (e.g. slide, aliquot, etc.). Data type CodeableConcept Binding Type of specimen container. SpecimenContainerType (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-27 rim: .code
capacity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.container.capacity Short description Container volume or size Definition The capacity (volume or other measure) the container may contain. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: one of: SAC 16, SAC17 and SAC 20, or SAC 21 and SAC 20 rim: .quantity
specimenQuantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.container.specimenQuantity Short description Quantity of specimen within container Definition The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-23 (value) SAC-24 (units rim: .playedRole[classCode=CONT].quantity
additive[x]		0..1		There are no (further) constraints on this element Element id Specimen.container.additive[x] Short description Additive associated with container Definition Introduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. Binding Substance added to specimen container. v2.0371 (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-27 rim: .scopesRole[classCode=ADTV].player
additiveCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
additiveReference			Reference(Substance)	There are no (further) constraints on this element Data type Reference(Substance)
condition	Σ	0..*	CodeableConceptBinding	There are no (further) constraints on this element Element id Specimen.condition Short description State of the specimen Definition A mode or state of being that describes the nature of the specimen. Requirements The specimen condition can be used to assess its quality or appropriateness for a specific test. Comments Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Data type CodeableConcept Binding Codes describing the state of the specimen. v2.0493 (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-24
note	S	0..2	Annotation	Element id Specimen.note Short description Kommentar des Probennehmers, Kommentar Definition To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value v2: NTE
id		0..1	string	There are no (further) constraints on this element Element id Specimen.note.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.note.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
author[x]	Σ	0..1		There are no (further) constraints on this element Element id Specimen.note.author[x] Short description Individual responsible for the annotation Definition The individual responsible for making the annotation. Comments Organization is used when there's no need for specific attribution as to who made the comment. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.participant[typeCode=AUT].role
authorString			string	There are no (further) constraints on this element Data type string
authorReference			Reference(Practitioner \| Patient \| RelatedPerson \| Organization)	There are no (further) constraints on this element Data type Reference(Practitioner \| Patient \| RelatedPerson \| Organization)
time	Σ	0..1	dateTime	There are no (further) constraints on this element Element id Specimen.note.time Short description When the annotation was made Definition Indicates when this particular annotation was made. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.effectiveTime
text	S Σ	1..1	markdown	There are no (further) constraints on this element Element id Specimen.note.text Short description The annotation - text content (as markdown) Definition The text of the annotation in markdown format. Data type markdown Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.text

Mapping

Logischer Datensatz	FHIR Element
Probendetails.Probenart	Specimen.type
Probendetails.LaborprobenIdentifikator	Specimen.accessionIdentifier
Probendetails.ExternerIdentifikator	Specimen.identifier
Probendetails.ZeitpunktdesProbeneingangs	Specimen.receivedTime
Probendetails.KommentardesProbennehmers	Specimen.note
Probendetails.Probenentnahmestelle	Specimen.collection.bodySite
Probendetails.NamederKörperstelle	Specimen.collection.bodySite.text
Probendetails.ZeitpunktderProbenentnahme	Specimen.collection.collectedDateTime
Probendetails.IdentifikatordesProbennehmers	Specimen.collection.collector
Probendetails.IdentifikatorderübergeordnetenProbe	Specimen.parent
Probendetails.Kommentar	Specimen.note

Logischer Datensatz	FHIR Element
Kultur.Isolatnummer	Specimen.accessionIdentifier

Constraints

Folgende Invarianten müssen bei der Implementierung des Profils beachtet werden:

Constraints:

key	severity	human	expression
Highmed-IC-Specimen-1	error	Falls ein Isolat kodiert wird, muss die Probe auch angeben werden	coding.where(code = '429951000124103' and system = 'http://snomed.info/sct').exists() implies %resource.parent.exists()

Terminology Bindings

Path	Name	Strength	URL
Specimen.type	probenart	extensible	http://highmed.org/fhir/ValueSet/ic/probenart
Specimen.collection.bodySite	probenentnahmestelle-mikrobiologischer-befund-snomedct	extensible	http://highmed.org/fhir/ValueSet/ic/probenentnahmestelle-mikrobiologischer-befund-snomedct

Snapshot

Profile_HiGHmed_InfectionControl_Specimen (Specimen)	I		Specimen	Element id Specimen Short description Sample for analysis Alternate names Probe Definition Eine physikalische Probe zur Erforschung, Untersuchung oder Analyse, die von einer Person entnommen wurde oder die sich auf die Person bezieht. Data type Specimen Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act rim: Role[classCode=SPEC]
id	Σ	0..1	string	There are no (further) constraints on this element Element id Specimen.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id Specimen.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Specimen.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id Specimen.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id Specimen.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Specimen.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	S Σ	0..*	Identifier	Element id Specimen.identifier Short description External Identifier Definition Eine eindeutige Kennung der Probe, die von einer Organisation außerhalb des Labors wie dem Auftraggeber zugeordnet wurde. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.identifier v2: SPM-2 rim: .id v2: OBR-2.1
accessionIdentifier	S Σ	1..1	Identifier	Element id Specimen.accessionIdentifier Short description Eine eindeutige Kennung der Probe, die normalerweise vom Labor vergeben wird. Definition The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.identifier v2: SPM-30 (v2.7+) rim: .participation[typeCode=SBJ].act[classCode=ACSN, moodCode=EVN].id v2: OBR-3.1
status	S Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id Specimen.status Short description available \| unavailable \| unsatisfactory \| entered-in-error Definition The availability of the specimen. Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding Codes providing the status/availability of a specimen. SpecimenStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.status v2: SPM-20 rim: status
type	S Σ I	1..1	CodeableConceptBinding	Element id Specimen.type Short description Kind of material that forms the specimen Definition The kind of material that forms the specimen. Comments The type can change the way that a specimen is handled and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems. Data type CodeableConcept Binding Use Case IC Probenart VS_Highmed_Probenart_Mikrobiologischer_Befund_SNOMEDCT (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Highmed-IC-Specimen-1: Falls ein Isolat kodiert wird, muss die Probe auch angeben werden `coding.where(code = '429951000124103' and system = 'http://snomed.info/sct').exists() implies %resource.parent.exists()` Mappings w5: FiveWs.what[x] v2: SPM-4 and possibly SPM-5 rim: .code v2: OBR-15
subject	S Σ	1..1	Reference(Patient \| Group \| Device \| Substance \| Location)	There are no (further) constraints on this element Element id Specimen.subject Short description Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device Definition Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance or a device. Requirements Must know the subject context. Data type Reference(Patient \| Group \| Device \| Substance \| Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.subject[x] rim: .scoper or .scoper.playsRole w5: FiveWs.subject
receivedTime	S Σ	0..1	dateTime	Element id Specimen.receivedTime Short description Datum und Uhrzeit des Eingangs der Probe im Labor. Definition Time when specimen was received for processing or testing. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.done[x] v2: SPM-18 rim: .participation[typeCode=SBJ].act[code=SPCREC, moodCode=EVN].effectiveTime v2: OBR-14
parent	S	0..1	Reference(Profile_HiGHmed_InfectionControl_Specimen)	Element id Specimen.parent Short description Specimen from which this specimen originated Definition Eindeutige Kennung der verwandten Probe(n), bei der die Probe in Teilproben aufgeteilt ist. Comments The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample. Data type Reference(Profile_HiGHmed_InfectionControl_Specimen) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .scoper (if parent) .player.scopesRole[classCode=SPEC].player (if child) v2: OBR-29
request		0..*	Reference(ServiceRequest)	There are no (further) constraints on this element Element id Specimen.request Short description Why the specimen was collected Definition Details concerning a service request that required a specimen to be collected. Comments The request may be explicit or implied such with a ServiceRequest that requires a blood draw. Data type Reference(ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.why[x] v2: ORC? OBR-2/3? rim: outboundRelationship[typeCode=FLFS].target
collection	S	1..1	BackboneElement	There are no (further) constraints on this element Element id Specimen.collection Short description Collection details Definition Details concerning the specimen collection. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-14 rim: .participation[typeCode=SBJ].act[classCode=SPECCOLLECT, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Specimen.collection.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.collection.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.collection.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
collector	S Σ	0..1	Reference(Practitioner \| PractitionerRole)	Element id Specimen.collection.collector Short description Die Person oder Organisation die für die Entnahme der Probe verantwortlich war. Definition Person who collected the specimen. Data type Reference(Practitioner \| PractitionerRole) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.actor v2: PRT rim: .participation[typeCode=PFM].role v2: OBR-10
collected[x]	S Σ I	1..1		Element id Specimen.collection.collected[x] Short description Collection time Definition Das Datum und die Uhrzeit, zu der die Probennahme angeordnet wurde oder stattfand. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.init v2: SPM-17 rim: .effectiveTime v2: OBR-7
collectedDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
collectedPeriod			Period	There are no (further) constraints on this element Data type Period
duration	Σ	0..1	Duration	There are no (further) constraints on this element Element id Specimen.collection.duration Short description How long it took to collect specimen Definition The span of time over which the collection of a specimen occurred. Data type Duration Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.init
quantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.collection.quantity Short description The quantity of specimen collected Definition The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-12 rim: .participation[typeCode=SBJ].role[classCode=SPEC].player.quantity
method		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.collection.method Short description Technique used to perform collection Definition A coded value specifying the technique that is used to perform the procedure. Data type CodeableConcept Binding The technique that is used to perform the procedure. FHIRSpecimenCollectionMethod (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-7 rim: .methodCode
bodySite	S	1..1	CodeableConceptBinding	Element id Specimen.collection.bodySite Short description Anatomical collection site Definition Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens. Comments If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension bodySite. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. VS_Highmed_Probenentnahmestelle_Mikrobiologischer_Befund_SNOMEDCT (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-8 and SPM-9 rim: .targetSiteCode v2: OBR-15.4,OBR-15.5
fastingStatus[x]	Σ	0..1	Binding	There are no (further) constraints on this element Element id Specimen.collection.fastingStatus[x] Short description Whether or how long patient abstained from food and/or drink Definition Abstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection. Requirements Many diagnostic tests require fasting to facilitate accurate interpretation. Comments Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/time] in 2 hour Urine --12 hours fasting), or using a component observation `such as`Observation.component code` = LOINC 49541-6 (Fasting status - Reported). Binding Codes describing the fasting status of the patient. v2.0916 (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBR-
fastingStatusCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
fastingStatusDuration			Duration	There are no (further) constraints on this element Data type Duration
processing		0..*	BackboneElement	There are no (further) constraints on this element Element id Specimen.processing Short description Processing and processing step details Definition Details concerning processing and processing steps for the specimen. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .participation[typeCode=SBJ].act[code=SPCTRT, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Specimen.processing.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.processing.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.processing.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
description		0..1	string	There are no (further) constraints on this element Element id Specimen.processing.description Short description Textual description of procedure Definition Textual description of procedure. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .text
procedure		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.processing.procedure Short description Indicates the treatment step applied to the specimen Definition A coded value specifying the procedure used to process the specimen. Data type CodeableConcept Binding Type indicating the technique used to process the specimen. SpecimenProcessingProcedure (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .code
additive		0..*	Reference(Substance)	There are no (further) constraints on this element Element id Specimen.processing.additive Short description Material used in the processing step Definition Material used in the processing step. Data type Reference(Substance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-6 rim: .participation[typeCode=CSM].role[classCode=ADTV].code
time[x]		0..1		There are no (further) constraints on this element Element id Specimen.processing.time[x] Short description Date and time of specimen processing Definition A record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .effectiveTime
timeDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
timePeriod			Period	There are no (further) constraints on this element Data type Period
container		0..*	BackboneElement	There are no (further) constraints on this element Element id Specimen.container Short description Direct container of specimen (tube/slide, etc.) Definition The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .player.scopingRole[classCode=CONT].scoper
id		0..1	string	There are no (further) constraints on this element Element id Specimen.container.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.container.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.container.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Specimen.container.identifier Short description Id for the container Definition Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-3 rim: .id
description		0..1	string	There are no (further) constraints on this element Element id Specimen.container.description Short description Textual description of the container Definition Textual description of the container. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .desc
type		0..1	CodeableConcept	There are no (further) constraints on this element Element id Specimen.container.type Short description Kind of container directly associated with specimen Definition The type of container associated with the specimen (e.g. slide, aliquot, etc.). Data type CodeableConcept Binding Type of specimen container. SpecimenContainerType (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-27 rim: .code
capacity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.container.capacity Short description Container volume or size Definition The capacity (volume or other measure) the container may contain. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: one of: SAC 16, SAC17 and SAC 20, or SAC 21 and SAC 20 rim: .quantity
specimenQuantity		0..1	SimpleQuantity	There are no (further) constraints on this element Element id Specimen.container.specimenQuantity Short description Quantity of specimen within container Definition The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-23 (value) SAC-24 (units rim: .playedRole[classCode=CONT].quantity
additive[x]		0..1		There are no (further) constraints on this element Element id Specimen.container.additive[x] Short description Additive associated with container Definition Introduced substance to preserve, maintain or enhance the specimen. Examples: Formalin, Citrate, EDTA. Binding Substance added to specimen container. v2.0371 (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SAC-27 rim: .scopesRole[classCode=ADTV].player
additiveCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
additiveReference			Reference(Substance)	There are no (further) constraints on this element Data type Reference(Substance)
condition	Σ	0..*	CodeableConceptBinding	There are no (further) constraints on this element Element id Specimen.condition Short description State of the specimen Definition A mode or state of being that describes the nature of the specimen. Requirements The specimen condition can be used to assess its quality or appropriateness for a specific test. Comments Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test. Data type CodeableConcept Binding Codes describing the state of the specimen. v2.0493 (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM-24
note	S	0..2	Annotation	Element id Specimen.note Short description Kommentar des Probennehmers, Kommentar Definition To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen). Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value v2: NTE
id		0..1	string	There are no (further) constraints on this element Element id Specimen.note.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Specimen.note.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
author[x]	Σ	0..1		There are no (further) constraints on this element Element id Specimen.note.author[x] Short description Individual responsible for the annotation Definition The individual responsible for making the annotation. Comments Organization is used when there's no need for specific attribution as to who made the comment. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.participant[typeCode=AUT].role
authorString			string	There are no (further) constraints on this element Data type string
authorReference			Reference(Practitioner \| Patient \| RelatedPerson \| Organization)	There are no (further) constraints on this element Data type Reference(Practitioner \| Patient \| RelatedPerson \| Organization)
time	Σ	0..1	dateTime	There are no (further) constraints on this element Element id Specimen.note.time Short description When the annotation was made Definition Indicates when this particular annotation was made. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.effectiveTime
text	S Σ	1..1	markdown	There are no (further) constraints on this element Element id Specimen.note.text Short description The annotation - text content (as markdown) Definition The text of the annotation in markdown format. Data type markdown Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: N/A rim: Act.text

Beispiele

{
    "resourceType": "Specimen",
    "id": "ExampleHiGHmedInfectionControlSpecimen",
    "meta": {
        "profile":  [
            "http://highmed.org/fhir/StructureDefinition/ic/Specimen"
        ]
    },
    "accessionIdentifier": {
        "system": "https://www.charite.de/fhir/CodeSystem/lab-identifiers",
        "assigner": {
            "reference": "Organization/Charite"
        }
    },
    "status": "available",
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "257261003",
                "display": "Swab (specimen)"
            }
        ]
    },
    "subject": {
        "reference": "Patient/ExampleHiGHmedInfectionControlPatient"
    },
    "collection": {
        "collectedDateTime": "05/16/2021 06:49:21",
        "bodySite": {
            "coding":  [
                {
                    "system": "http://snomed.info/sct",
                    "code": "53505006",
                    "display": "Anal structure (body structure)"
                }
            ]
        }
    }
}