Leitfaden Basis DE (STU3)

Basisprofil Diagnose

Diagnose, Gesundheitszustand

Basisprofil Diagnose

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

condition-de-basis-0.2 (Condition)	I		Condition	There are no (further) constraints on this element Element id Condition Short description Detailed information about conditions, problems or diagnoses Definition A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern. Data type Condition Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative `contained.text.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-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource `contained.where(('#'+id in %resource.descendants().reference).not()).empty()` con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission `abatement.empty() or (abatement as boolean).not() or clinicalStatus='resolved' or clinicalStatus='remission' or clinicalStatus='inactive'` con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error `verificationStatus='entered-in-error' or clinicalStatus.exists()` Mappings rim: Entity. Role, or Act sct-concept: < 243796009 \|Situation with explicit context\|: 246090004 \|Associated finding\| = ((< 404684003 \|Clinical finding\| MINUS << 420134006 \|Propensity to adverse reactions\| MINUS << 473010000 \|Hypersensitivity condition\| MINUS << 79899007 \|Drug interaction\| MINUS << 69449002 \|Drug action\| MINUS << 441742003 \|Evaluation finding\| MINUS << 307824009 \|Administrative status\| MINUS << 385356007 \|Tumor stage finding\|) OR < 272379006 \|Event\|) v2: PPR message rim: Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis] w5: clinical.general
id	Σ	0..1	id	There are no (further) constraints on this element Element id Condition.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 id
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id Condition.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 may not always be associated with version changes to the resource. Data type Meta
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id Condition.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. 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. This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation. Data type uri
language		0..1	codeBinding	There are no (further) constraints on this element Element id Condition.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. Common Languages (extensible)
text	I	0..1	Narrative	There are no (further) constraints on this element Element id Condition.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 may 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 in formation is added later. Data type Narrative Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id Condition.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. Data type Resource Mappings rim: N/A
extension		0..*	Extension	Element id Condition.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. In order 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. 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) Mappings rim: N/A
Diagnosesicherheit	I	0..1	Extension(CodeableConcept)	Element id Condition.extension:Diagnosesicherheit Short description Diagnosesicherheit lt. ICD-10-GM Alternate names extensions, user content Definition Diese Extension kann zur Angabe der Diagnosesicherung in ICD-10-GM-Codierung verwendet werden. Die Angabe der äquivalenten Werte für clinicalStatus und verificationStatus ist in diesem Fall dennoch zwingend. Die Äquivalente gelten wie folgt: "A" (ausgeschlossen) => clinicalStatus = leer, verificationStatus="refuted" "G" (gesicherte Diagnose) => clinicalStatus = "active", verificationStatus="confirmed" "V" (Verdacht auf / zum Ausschluss von) => clinicalStatus = "active", verificationStatus="provisional" "Z" (Zustand nach) => clinicalStatus = "resolved", verificationStatus="confirmed" 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(CodeableConcept) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit/0.2 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A rim: n/a
modifierExtension	?!	0..*	Extension	There are no (further) constraints on this element Element id Condition.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. Usually modifier elements provide negation or qualification. In order 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. 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 Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id Condition.identifier Short description External Ids for this condition Definition This records identifiers associated with this condition that are defined by business processes and/or used to refer to it when a direct URL reference to the resource itself is not appropriate (e.g. in CDA documents, or in written / printed documentation). Requirements Need to allow connection to a wider workflow. Data type Identifier Mappings rim: .id w5: id
clinicalStatus	Σ ?! I	0..1	codeBinding	There are no (further) constraints on this element Element id Condition.clinicalStatus Short description active \| recurrence \| inactive \| remission \| resolved Definition The clinical status of the condition. Comments This element is labeled as a modifier because the status contains codes that mark the condition as not currently valid or of concern. Data type code Binding The clinical status of the condition or diagnosis. Condition Clinical Status Codes (required) Mappings sct-concept: < 303105007 \|Disease phases\| v2: PRB-14 / DG1-6 rim: Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value w5: status
verificationStatus	Σ ?! I	0..1	codeBinding	There are no (further) constraints on this element Element id Condition.verificationStatus Short description provisional \| differential \| confirmed \| refuted \| entered-in-error \| unknown Definition The verification status to support the clinical status of the condition. Comments verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid. Data type code Binding The verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required) Default value unknown Mappings sct-concept: < 410514004 \|Finding context value\| v2: PRB-13 rim: Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value sct-attr: 408729009 w5: status
category		0..*	CodeableConcept	There are no (further) constraints on this element Element id Condition.category Short description problem-list-item \| encounter-diagnosis Definition A category assigned to the condition. Comments The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. Data type CodeableConcept Binding A category assigned to the condition. Condition Category Codes (example) Mappings sct-concept: < 404684003 \|Clinical finding\| v2: 'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message rim: .code w5: class
severity		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Condition.severity Short description Subjective severity of condition Definition A subjective assessment of the severity of the condition as evaluated by the clinician. Comments Coding of the severity with a terminology is preferred, where possible. Data type CodeableConcept Binding A subjective assessment of the severity of the condition as evaluated by the clinician. Condition/Diagnosis Severity (preferred) Mappings sct-concept: < 272141005 \|Severities\| v2: PRB-26 / ABS-3 rim: Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value sct-attr: 246112005 w5: grade
code	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id Condition.code Short description Identification of the condition, problem or diagnosis Alternate names type Definition Identification of the condition, problem or diagnosis. Requirements 0..1 to account for primarily narrative only resources. Data type CodeableConcept Binding Identification of the condition or diagnosis. Condition/Problem/Diagnosis Codes (example) Mappings sct-concept: code 246090004 \|Associated finding\| (< 404684003 \|Clinical finding\| MINUS << 420134006 \|Propensity to adverse reactions\| MINUS << 473010000 \|Hypersensitivity condition\| MINUS << 79899007 \|Drug interaction\| MINUS << 69449002 \|Drug action\| MINUS << 441742003 \|Evaluation finding\| MINUS << 307824009 \|Administrative status\| MINUS << 385356007 \|Tumor stage finding\|) OR < 413350009 \|Finding with explicit context\| OR < 272379006 \|Event\| v2: PRB-3 rim: .value sct-attr: 246090004 w5: what
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	There are no (further) constraints on this element Element id Condition.code.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. In order 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. 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 Mappings rim: n/a
coding	Σ	0..*	Coding	Element id Condition.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data type Coding Sliced: Unordered, Open, by system(Value) Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ICD-10-GM	Σ	0..*	CodingBinding	Element id Condition.code.coding:ICD-10-GM Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data type Coding Binding icd-10-gm (required) Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	Element id Condition.code.coding:ICD-10-GM.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. In order 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. 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 Mappings rim: n/a
Haupt-Code_Kreuz-Code	I	0..1	Extension(CodeableConcept)	Element id Condition.code.coding:ICD-10-GM.extension:Haupt-Code_Kreuz-Code Short description Der Haupt- bzw. Kreuz-Code Alternate names extensions, user content Definition Optional Extension Element - found in all resources. 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(CodeableConcept) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz/0.2 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Stern-Code	I	0..*	Extension(CodeableConcept)	Element id Condition.code.coding:ICD-10-GM.extension:Stern-Code Short description Stern-Code Alternate names extensions, user content Definition Optional Extension Element - found in all resources. 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(CodeableConcept) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-stern/0.2 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
Ausrufezeichen-Code	I	0..*	Extension(CodeableConcept)	Element id Condition.code.coding:ICD-10-GM.extension:Ausrufezeichen-Code Short description Ausrufezeichen-Code Alternate names extensions, user content Definition Optional Extension Element - found in all resources. 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(CodeableConcept) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen/0.2 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
system	Σ	1..1	uriFixed Value	Element id Condition.code.coding:ICD-10-GM.system Short description ICD-10-GM Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data type uri Fixed value http://fhir.de/CodeSystem/dimdi/icd-10-gm Mappings v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	1..1	string	Element id Condition.code.coding:ICD-10-GM.version Short description Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Mappings v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	Element id Condition.code.coding:ICD-10-GM.code Short description Der ICD-10-Code Definition Der ICD-10-Code, einschließlich verbundener Codes (Kreuz-Stern-Notation, Ausrufezeichen-Notation. Vgl. hierzu auch die Dokumentation zu iCD in der FHIR-Spezifikation. Die Einzelbestandteile von postkoordinierten Codes (einzelne ICD-10-GM-Codes) können über die im Profil definierten Extensions einzeln dokumentiert werden. Die Angabe des postkoordinierten Codes ist in diesem Fall dennoch zwingend. Seitenlokalisaion und Diagnosesichrheit sollten, soweit vorhanden, in den Elementen bodySite bzw. clinicalStatus/verificationStatus codiert werden. Für die Diagnosesicherkeit kann zusätzlich auch die entsprechende Extension verwendet werden. Die Angabe von clinicalStatus und/oder verificationStatus ist jedoch in diesen Fällen zwingend, da es sich hierbei um modifizierende Angaben (modyfiers) handelt. Requirements Need to refer to a particular code in the system. Data type code Mappings v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Data type string Mappings v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Mappings v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.code.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data type string Mappings v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id Condition.bodySite Short description Anatomical location, if relevant Definition The anatomical location where this condition manifests itself. Comments Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMED CT Body Structures (example) Mappings sct-concept: < 442083009 \|Anatomical or acquired body structure\| rim: .targetBodySiteCode sct-attr: 363698007
id		0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	Element id Condition.bodySite.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. In order 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. 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 Mappings rim: n/a
Lokalisations-Referenz	I	0..1	Extension(Reference(BodySite))	Element id Condition.bodySite.extension:Lokalisations-Referenz Short description Lokalisations-Referenz Alternate names extensions, user content Definition Referenz auf eine Lokalisation. Zur detaillierteren Darstellung von Lokalisationen mittels der BodySite-Ressource Hinweis: ab FHIR R4 wird diese Ressource als BodyStructure bezeichnet, dementsprechend ändert sich dann auch der Name der 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(Reference(BodySite)) Extension URL http://hl7.org/fhir/StructureDefinition/body-site-instance Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.extension:Lokalisations-Referenz.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	There are no (further) constraints on this element Element id Condition.bodySite.extension:Lokalisations-Referenz.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. In order 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. 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 Mappings rim: n/a
url		1..1	uriFixed Value	There are no (further) constraints on this element Element id Condition.bodySite.extension:Lokalisations-Referenz.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data type uri Fixed value http://hl7.org/fhir/StructureDefinition/body-site-instance Mappings rim: N/A
valueReference		0..1	Reference(BodySite)	There are no (further) constraints on this element Element id Condition.bodySite.extension:Lokalisations-Referenz.valueReference:valueReference Short description Value of extension Definition Value of extension - may be a resource or one of a constrained set of the data types (see Extensibility in the spec for list). Data type Reference(BodySite) Mappings rim: N/A
coding	Σ	0..*	Coding	Element id Condition.bodySite.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data type Coding Sliced: Unordered, Open, by system(Value) Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ICD-10-GM-Seitenlokalisation	Σ	0..1	CodingBinding	Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings. Comments Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Data type Coding Binding ?? (required) Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.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. In order 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. 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 Mappings rim: n/a
system	Σ	1..1	uriFixed Value	Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously. Data type uri Fixed value http://fhir.de/CodeSystem/kbv/s_icd_seitenlokalisation Mappings v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Mappings v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Data type code Mappings v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Data type string Mappings v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id Condition.bodySite.coding:ICD-10-GM-Seitenlokalisation.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - i.e. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Mappings v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.bodySite.text Short description Plain text representation of the concept Definition A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. Requirements The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Comments Very often the text is the same as a displayName of one of the codings. Data type string Mappings v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	Σ	1..1	Reference(Group \| Patient, deutsches Basisprofil (Version 0.2))	Element id Condition.subject Short description Who has the condition? Alternate names patient Definition Indicates the patient or group who the condition record is associated with. Requirements Group is typically used for veterinary or public health use cases. Data type Reference(Group \| Patient, deutsches Basisprofil (Version 0.2)) Mappings v2: PID-3 rim: .participation[typeCode=SBJ].role[classCode=PAT] w5: who.focus
context	Σ	0..1	Reference(Encounter \| EpisodeOfCare)	There are no (further) constraints on this element Element id Condition.context Short description Encounter or episode when condition first asserted Alternate names encounter Definition Encounter during which the condition was first asserted. Comments This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known". Data type Reference(Encounter \| EpisodeOfCare) Mappings v2: PV1-19 (+PV1-54) rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN] w5: context
onset[x]	Σ	0..1		There are no (further) constraints on this element Element id Condition.onset[x] Short description Estimated or actual date, date-time, or age Definition Estimated or actual date or date-time the condition began, in the opinion of the clinician. Comments Age is generally used when the patient reports an age at which the Condition began to occur. Mappings v2: PRB-16 rim: .effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value w5: when.init
onsetDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
onsetAge			Age	There are no (further) constraints on this element Data type Age
onsetPeriod			Period	There are no (further) constraints on this element Data type Period
onsetRange			Range	There are no (further) constraints on this element Data type Range
onsetString			string	There are no (further) constraints on this element Data type string
abatement[x]	I	0..1		There are no (further) constraints on this element Element id Condition.abatement[x] Short description If/when in resolution/remission Definition The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate. Comments There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated. Mappings rim: .effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed w5: when.done
abatementDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
abatementAge			Age	There are no (further) constraints on this element Data type Age
abatementBoolean			boolean	There are no (further) constraints on this element Data type boolean
abatementPeriod			Period	There are no (further) constraints on this element Data type Period
abatementRange			Range	There are no (further) constraints on this element Data type Range
abatementString			string	There are no (further) constraints on this element Data type string
assertedDate	Σ	0..1	dateTime	There are no (further) constraints on this element Element id Condition.assertedDate Short description Date record was believed accurate Definition The date on which the existance of the Condition was first asserted or acknowledged. Comments The assertedDate represents the date when this particular Condition record was created in the EHR, not the date of the most recent update in terms of when severity, abatement, etc. were specified. The date of the last record modification can be retrieved from the resource metadata. Data type dateTime Mappings v2: REL-11 rim: .participation[typeCode=AUT].time w5: when.recorded
asserter	Σ	0..1	Reference(RelatedPerson \| Patient, deutsches Basisprofil (Version 0.2) \| Practitioner, deutsches Basisprofil (Version 0.2))	Element id Condition.asserter Short description Person who asserts this condition Definition Individual who is making the condition statement. Data type Reference(RelatedPerson \| Patient, deutsches Basisprofil (Version 0.2) \| Practitioner, deutsches Basisprofil (Version 0.2)) Mappings v2: REL-7.1 identifier + REL-7.12 type code rim: .participation[typeCode=AUT].role w5: who.author
stage	I	0..1	BackboneElement	There are no (further) constraints on this element Element id Condition.stage Short description Stage/grade, usually assessed formally Definition Clinical stage or grade of a condition. May include formal severity assessments. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` con-1: Stage SHALL have summary or assessment `summary.exists() or assessment.exists()` Mappings rim: ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
id		0..1	string	There are no (further) constraints on this element Element id Condition.stage.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	There are no (further) constraints on this element Element id Condition.stage.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. In order 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. 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 Mappings rim: n/a
modifierExtension	Σ ?!	0..*	Extension	There are no (further) constraints on this element Element id Condition.stage.modifierExtension Short description Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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 Mappings rim: N/A
summary	I	0..1	CodeableConcept	There are no (further) constraints on this element Element id Condition.stage.summary Short description Simple summary (disease specific) Definition A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Data type CodeableConcept Binding Codes describing condition stages (e.g. Cancer stages). Condition Stage (example) Mappings sct-concept: < 254291000 \|Staging and scales\| v2: PRB-14 rim: .value
assessment	I	0..*	Reference(ClinicalImpression \| DiagnosticReport \| Observation)	There are no (further) constraints on this element Element id Condition.stage.assessment Short description Formal record of assessment Definition Reference to a formal record of the evidence on which the staging assessment is based. Data type Reference(ClinicalImpression \| DiagnosticReport \| Observation) Mappings rim: .self
evidence	I	0..*	BackboneElement	There are no (further) constraints on this element Element id Condition.evidence Short description Supporting evidence Definition Supporting Evidence / manifestations that are the basis on which this condition is suspected or confirmed. Comments The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() \| (children().count() > id.count())` con-2: evidence SHALL have code or details `code.exists() or detail.exists()` Mappings rim: .outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Condition.evidence.id Short description xml:id (or equivalent in JSON) 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		0..*	Extension	There are no (further) constraints on this element Element id Condition.evidence.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. In order 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. 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 Mappings rim: n/a
modifierExtension	Σ ?!	0..*	Extension	There are no (further) constraints on this element Element id Condition.evidence.modifierExtension Short description Extensions that cannot be ignored 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 that contains it. Usually modifier elements provide negation or qualification. In order 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. 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 Mappings rim: N/A
code	Σ I	0..*	CodeableConcept	There are no (further) constraints on this element Element id Condition.evidence.code Short description Manifestation/symptom Definition A manifestation or symptom that led to the recording of this condition. Data type CodeableConcept Binding Codes that describe the manifestation or symptoms of a condition. Manifestation and Symptom Codes (example) Mappings sct-concept: < 404684003 \|Clinical finding\| rim: [code="diagnosis"].value w5: why
detail	Σ I	0..*	Reference(Resource)	There are no (further) constraints on this element Element id Condition.evidence.detail Short description Supporting information found elsewhere Definition Links to other relevant information, including pathology reports. Data type Reference(Resource) Mappings rim: .self w5: why
note		0..*	Annotation	There are no (further) constraints on this element Element id Condition.note Short description Additional information about the Condition Definition Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. Data type Annotation Mappings v2: NTE child of PRB rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value

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"
    }
}