Befunde (Bundle)

Um die diabetesbezogenen Therapiedaten des Patienten zu vervollständigen, kann ein Arzt medizinische Befunde wie z. B. HbA1c-Werte im ESYSTA Portal eintragen. Die folgende Festlegung beschreibt ein Bundle das ein oder mehrere Befundsdaten als entry beinhaltet. Die Einträge können ein klinischer Zustand, ein Problem, eine Diagnose oder ein anderes Ereignis sein und werden jeweils als Condition-Ressource abgebildet.

Kompatibilität

Dieses Profil basiert auf der Basisdefinition des FHIR Bundle und beinhaltet mehrere FHIR Conditions. Instanzen müssen gegen das folgende FHIR-Profil valide sein.

FHIR-Profil (MedicalFindingsBundle)

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
id0..1string
extensionI0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemS Σ1..1uriPattern
valueS Σ1..1string
periodΣ I0..1Period
assignerΣ I0..1Reference(Organization)
typeΣ1..1codeBindingFixed Value
timestampΣ0..1instant
totalΣ I0..1unsignedInt
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
relationΣ1..1string
urlΣ1..1uri
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
fullUrlΣ0..1uri
resourceΣ0..1Condition
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
modeΣ0..1codeBinding
scoreΣ0..1decimal
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
methodΣ1..1codeBinding
urlΣ1..1uri
ifNoneMatchΣ0..1string
ifModifiedSinceΣ0..1instant
ifMatchΣ0..1string
ifNoneExistΣ0..1string
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
statusΣ1..1string
locationΣ0..1uri
etagΣ0..1string
lastModifiedΣ0..1instant
outcomeΣ0..1Resource
signatureΣ0..1Signature

Beispiel

Fiktives Beispiel einer validen MedicalFindingsBundle Instanz:

<Bundle xmlns="http://hl7.org/fhir">
    <id value="export-1-medical-findings" />
    <meta>
        <profile value="http://portal.esysta.com/fhir/StructureDefinition/MedicalFindingsBundle" />
    </meta>
    <identifier>
        <system value="http://portal.esysta.com/fhir/Bundle/" />
        <value value="export-1-medical-findings" />
    </identifier>
    <type value="collection" />
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-diab" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-diab" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-diab" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                        <code value="E11.40" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
                <note>
                    <text value="E11.20G, E11.60G, E11.61G, E11.50G" />
                </note>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-phys" />
        <resource>
            <Observation>
                <id value="medical-findings-1-phys" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Observation/" />
                    <value value="medical-findings-1-phys" />
                </identifier>
                <status value="final" />
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="425044008" />
                        <display value="Physical exam section" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <effectiveDateTime value="2021-03-17T15:58:00.725727Z" />
                <performer>
                    <reference value="Practitioner/practitioner-1" />
                </performer>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="50373000" />
                            <display value="Body height" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="180" />
                        <unit value="cm" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="cm" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="27113001" />
                            <display value="Body weight" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="150" />
                        <unit value="kg" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="kg" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="276361009" />
                            <display value="Waist circumference" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="130" />
                        <unit value="cm" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="cm" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="271649006" />
                            <display value="Systolic blood pressure" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="180" />
                        <unit value="mmHg" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="mm[Hg]" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="271650006" />
                            <display value="Diastolic blood pressure" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="110" />
                        <unit value="mmHg" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="mm[Hg]" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="6797001" />
                            <display value="MAP - Mean arterial pressure" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="140" />
                        <unit value="mmHg" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="mm[Hg]" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="250908004" />
                            <display value="Left ventricular ejection fraction" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="45" />
                        <unit value="%" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="%" />
                    </valueQuantity>
                </component>
            </Observation>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-lab" />
        <resource>
            <Observation>
                <id value="medical-findings-1-lab" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Observation/" />
                    <value value="medical-findings-1-lab" />
                </identifier>
                <status value="final" />
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="118246004" />
                        <display value="Laboratory test observations" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <effectiveDateTime value="2021-03-17T15:58:00.725727Z" />
                <performer>
                    <reference value="Practitioner/practitioner-1" />
                </performer>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="443911005" />
                            <display value="HBA1c (Hemoglobin A1c) level" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="9.6" />
                        <unit value="%" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="%" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="45154002" />
                            <display value="Glucosuria" />
                        </coding>
                    </code>
                    <valueBoolean value="true" />
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="365757006" />
                            <display value="Serum creatinine level" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="23" />
                        <unit value="mg/dL" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="mg/dL" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="102811001" />
                            <display value="Creatinine renal clearance" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="180" />
                        <unit value="ml/min" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="ml/min" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="274769005" />
                            <display value="Albuminuria" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="80" />
                        <unit value="mg/d" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="mg/d" />
                    </valueQuantity>
                </component>
            </Observation>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-events" />
        <resource>
            <Observation>
                <id value="medical-findings-1-events" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Observation/" />
                    <value value="medical-findings-1-events" />
                </identifier>
                <status value="final" />
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="74964007" />
                        <display value="Other" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <effectiveDateTime value="2021-03-17T15:58:00.725727Z" />
                <performer>
                    <reference value="Practitioner/practitioner-1" />
                </performer>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="237632004" />
                            <display value="Hypoglycemic event due to diabetes" />
                        </coding>
                    </code>
                    <valueInteger value="2" />
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="276076006" />
                            <display value="Excess sick leave" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="23" />
                        <unit value="d" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="d" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="160741006" />
                            <display value="Long stay hospital inpatient" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="3" />
                        <unit value="d" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="d" />
                    </valueQuantity>
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="25876001" />
                            <display value="Emergency" />
                        </coding>
                    </code>
                    <valueInteger value="1" />
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://loinc.org" />
                            <code value="80391-6" />
                            <display value="Level of care [Type]" />
                        </coding>
                    </code>
                    <valueInteger value="1" />
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="103696004" />
                            <display value="Patient referral to specialist" />
                        </coding>
                    </code>
                    <valueBoolean value="false" />
                </component>
                <component>
                    <code>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="768730001" />
                            <display value="Home health aide" />
                        </coding>
                    </code>
                    <valueQuantity>
                        <value value="23" />
                        <unit value="h/wk" />
                        <system value="http://unitsofmeasure.org" />
                        <code value="h/wk" />
                    </valueQuantity>
                </component>
            </Observation>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-aht" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-aht" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-aht" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="38341003" />
                        <display value="Hypertension" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-stroke" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-stroke" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-stroke" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="refuted" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="230690007" />
                        <display value="Stroke" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-lmd" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-lmd" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-lmd" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="267431006" />
                        <display value="Lipid metabolism disorder" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-chd" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-chd" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-chd" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="53741008" />
                        <display value="Coronary heart disease" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-paod" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-paod" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-paod" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="399957001" />
                        <display value="Peripheral artery occlusive disease" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-arrythmia" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-arrythmia" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-arrhythmia" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="698247007" />
                        <display value="Cardiac arrhythmia" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-ecg" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-ecg" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-ecg" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="102594003" />
                        <display value="Abnormal ECG" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-mi" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-mi" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-mi" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="22298006" />
                        <display value="Myocardial infarction" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
            </Condition>
        </resource>
    </entry>
    <entry>
        <fullUrl value="http://portal.esysta.com/fhir/Bundle/medical-findings-1-cond-chf" />
        <resource>
            <Condition>
                <id value="medical-findings-1-cond-chf" />
                <identifier>
                    <use value="official" />
                    <system value="http://portal.esysta.com/fhir/Condition/" />
                    <value value="medical-findings-1-cond-chf" />
                </identifier>
                <verificationStatus>
                    <coding>
                        <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
                        <code value="confirmed" />
                    </coding>
                </verificationStatus>
                <code>
                    <coding>
                        <system value="http://snomed.info/sct" />
                        <code value="48447003" />
                        <display value="Chronic heart failure" />
                    </coding>
                </code>
                <subject>
                    <reference value="Patient/patient-1" />
                </subject>
                <recordedDate value="2021-03-17T15:58:00.725727Z" />
                <recorder>
                    <reference value="Practitioner/practitioner-1" />
                </recorder>
                <stage>
                    <summary>
                        <coding>
                            <system value="http://snomed.info/sct" />
                            <code value="60333009" />
                        </coding>
                    </summary>
                </stage>
            </Condition>
        </resource>
    </entry>
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