Diagnose, Gesundheitszustand

Basisprofil Diagnose

Canonical URL: http://fhir.de/StructureDefinition/condition-de-basis/0.2

DiagnosesicherheitI0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusΣ ?! I0..1codeBinding
verificationStatusΣ ?! I0..1codeBinding
category0..*CodeableConcept
severity0..1CodeableConceptBinding
Haupt-Code_Kreuz-CodeI0..1Extension(CodeableConcept)
Stern-CodeI0..*Extension(CodeableConcept)
Ausrufezeichen-CodeI0..*Extension(CodeableConcept)
systemΣ1..1uriFixed Value
versionΣ1..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
url1..1uriFixed Value
valueReference0..1Reference(BodySite)
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectΣ I1..1Reference(Group | Patient, deutsches Basisprofil (Version 0.2))
contextΣ I0..1Reference(Encounter | EpisodeOfCare)
onsetDateTimedateTime
onsetAgeAge
onsetPeriodPeriod
onsetRangeRange
onsetStringstring
abatementDateTimedateTime
abatementAgeAge
abatementBooleanboolean
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
assertedDateΣ0..1dateTime
asserterΣ I0..1Reference(RelatedPerson | Patient, deutsches Basisprofil (Version 0.2) | Practitioner, deutsches Basisprofil (Version 0.2))
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
note0..*Annotation

Beispiele

XML-Format

Einfache Diagnose:

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" />
    </meta>
    <text>
        <status value="generated" />
        --- We have skipped the narrative for better readability of the resource ---
    </text>
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2017" />
            <code value="Q90.0" />
            <display value="Trisomie 21, meiotische Non-disjunction" />
        </coding>
        <text value="Trisomie 21, meiotische Non-disjunction" />
    </code>
    <subject>
        <reference value="Patient/12345" />
    </subject>
</Condition>

Diagnose mit Seitenlokalisation:

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" />
    </meta>
    <text>
        <status value="generated" />
        --- We have skipped the narrative for better readability of the resource ---
    </text>
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2017" />
            <code value="S51.9" />
            <display value="Schnittwunde am Unterarm" />
        </coding>
        <text value="Schnittwunde am Unterarm" />
    </code>
    <bodySite>
        <coding>
            <system value="http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation" />
            <code value="L" />
            <display value="links" />
        </coding>
        <text value="links" />
    </bodySite>
    <subject>
        <reference value="Patient/12345" />
    </subject>
</Condition>

Diagnose mit Angabe der Diagnosesicherheit:

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" />
    </meta>
    <text>
        <status value="generated" />
        --- We have skipped the narrative for better readability of the resource ---
    </text>
    <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2">
        <valueCodeableConcept>
            <coding>
                <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" />
                <code value="V" />
            </coding>
        </valueCodeableConcept>
    </extension>
    <clinicalStatus value="active" />
    <verificationStatus value="provisional" />
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2017" />
            <code value="I21.9" />
            <display value="Herzinfarkt" />
        </coding>
        <text value="Herzinfarkt" />
    </code>
    <subject>
        <reference value="Patient/12345" />
    </subject>
</Condition>

Diagnose mit Angabe der Seitenlokalisation und der Diagnosesicherheit:

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-basis/0.2" />
    </meta>
    <text>
        <status value="generated" />
        --- We have skipped the narrative for better readability of the resource ---
    </text>
    <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2">
        <valueCodeableConcept>
            <coding>
                <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" />
                <code value="G" />
            </coding>
        </valueCodeableConcept>
    </extension>
    <clinicalStatus value="active" />
    <verificationStatus value="confirmed" />
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2017" />
            <code value="S51.9" />
            <display value="Schnittwunde am Unterarm" />
        </coding>
        <text value="Schnittwunde am Unterarm" />
    </code>
    <bodySite>
        <coding>
            <system value="http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation" />
            <code value="L" />
            <display value="links" />
        </coding>
        <text value="links" />
    </bodySite>
    <subject>
        <reference value="Patient/12345" />
    </subject>
</Condition>

JSON-Format

Einfache Diagnose:

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-basis/0.2"
        ]
    },
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2017",
                "code": "Q90.0",
                "display": "Trisomie 21, meiotische Non-disjunction"
            }
        ],
        "text": "Trisomie 21, meiotische Non-disjunction"
    },
    "subject": {
        "reference": "Patient/12345"
    }
}

Diagnose mit Seitenlokalisation:

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-basis/0.2"
        ]
    },
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2017",
                "code": "S51.9",
                "display": "Schnittwunde am Unterarm"
            }
        ],
        "text": "Schnittwunde am Unterarm"
    },
    "bodySite":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation",
                    "code": "L",
                    "display": "links"
                }
            ],
            "text": "links"
        }
    ],
    "subject": {
        "reference": "Patient/12345"
    }
}

Diagnose mit Angabe der Diagnosesicherheit:

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-basis/0.2"
        ]
    },
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "extension":  [
        {
            "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit",
                        "code": "V"
                    }
                ]
            }
        }
    ],
    "clinicalStatus": "active",
    "verificationStatus": "provisional",
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2017",
                "code": "I21.9",
                "display": "Herzinfarkt"
            }
        ],
        "text": "Herzinfarkt"
    },
    "subject": {
        "reference": "Patient/12345"
    }
}

Diagnose mit Angabe der Seitenlokalisation und der Diagnosesicherheit:

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-basis/0.2"
        ]
    },
    "text": {
        "status": "generated",
        --- We have skipped the narrative for better readability of the resource ---
    },
    "extension":  [
        {
            "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "system": "http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit",
                        "code": "G"
                    }
                ]
            }
        }
    ],
    "clinicalStatus": "active",
    "verificationStatus": "confirmed",
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2017",
                "code": "S51.9",
                "display": "Schnittwunde am Unterarm"
            }
        ],
        "text": "Schnittwunde am Unterarm"
    },
    "bodySite":  [
        {
            "coding":  [
                {
                    "system": "http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation",
                    "code": "L",
                    "display": "links"
                }
            ],
            "text": "links"
        }
    ],
    "subject": {
        "reference": "Patient/12345"
    }
}