Medical Informatics Initiative - CORD - ImplementationGuide

Condition

Example of a diagnosis 'Farber-Lipogranulomatose'

{
    "resourceType": "Condition",
    "id": "ExampleRareDisease",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/CORD/StructureDefinition/Diagnose"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm",
                "version": "2021",
                "code": "E75.2",
                "display": "Sonstige Sphingolipidosen"
            },
            {
                "system": "http://fhir.de/CodeSystem/bfarm/alpha-id",
                "code": "I118641",
                "version": "2021"
            },
            {
                "system": "http://www.orpha.net",
                "code": "333",
                "display": "Farber-Lipogranulomatose"
            }
        ]
    },
    "subject": {
        "reference": "Patient/654321"
    },
    "encounter": {
        "reference": "Encounter/654321"
    },
    "onsetPeriod": {
        "start": "2021-12-13T16:00:00+01:00"
    },
    "recordedDate": "2021-12-13T18:00:00+01:00"
}

Differential:

FHIR element	Explanation
Condition.id	Must-support, but optional
Condtion.meta	Must-support, but optional
Condtion.clinicalStatus	No restrictions, complete diagnostic workflow is supported. The element is optional because it is not recorded routinely. In addition, the status is not usually captured at discharge.
Condtion.code	Min. 1 coded diagnosis has to be included. System can be selected from Alpha-ID, SNOMED CT, Orpahanet and ICD-10 GM.
Condtion.code.coding:icd10-gm.extension	Within the extensions "AusrufezeichenCode", "ManifestationsCode" and "Primaercode", the respective code components should be coded without respective special characters (e.g. "!", "+" or "*").
Condtion.bodySite	In case this optional element is used, the body site has to be coded at least with one SNOMED-CT code. It is not necessary to specify the laterality here, this should be specified per Condition.code.coding:icd10-gm.extenison:site localization. This field is used to document additional information (beyond the code) about the manifestation.
Condtion.subject	The reference to the module person is always given.
Condition.encounter	It should be noted that in most cases this field should not be used to link the case and the diagnosis. This element is used to link the diagnosis to the encounter / contact in which the diagnosis is determined (always a contact with a concrete care center!). In general, the linking should be done via Encounter.diagnosis.
Condtion.onset[x]	Following the IPS, it can be coded as Period or dateTime. Life phases can additionally be specified if exact times are unknown.
Condtion.recordedDate	Serves for the chronological classification of the diagnosis (instead of the queries on the initial 'Abteilungsfall' of the determination of the diagnosis).
Condtion.note	Additional explanation of the diagnosis.

FHIR element	Explanation
Encounter.period.start / Diagnose.encounter	It should be noted that the mapping of the logical data element "Feststellungsdatum" is not performed on the Condition resource but on the Encounter resource. Thus, the linking of the diagnosis SHOULD always be done to a facility contact (See Case module).

FHIR Element	Logical dataset
Condition.code:icd-10gm	Diagnose.ICD10GMDiagnoseKodiert
Condition.code:icd-10gm.coding.code	Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:icd-10gm.coding:extension:Primaercode	Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode
Condition.code:icd-10gm.coding:extension:ManifestationsCode	Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode
Condition.code:icd-10gm.coding:extension:AusrufezeichenCode	Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode
Condition.code:icd-10gm.coding:extension:Diagnosesicherheit	Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit
Condition.code:icd-10gm.coding:extension:Seitenlokalisation	Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation
Condition.code:alpha-id	Diagnose.ALPHAIDDiagnoseKodiert
Condition.code:alpha-id (coding.system, coding.value)	Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:orphanet	Diagnose.ORPHANETDiagnoseKodiert
Condition.code:orphanet (coding.system, coding.value)	Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:sct	Diagnose.SNOMEDDiagnoseKodiert
Condition.code:sct (coding.system, coding.value)	Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode
Condition.code	Diagnose.WeitereKodiersysteme
Condition.code (coding.system, coding.value)	Diagnose.WeitereKodesysteme.VollständigerDiagnosecode
Condition.bodySite	Diagnose.Körperstelle
Condition.code.text	Diagnose.Freitextbeschreibung
Condition.note	Diagnose.Diagnoseerläuterung
Condition.recordedDate	Diagnose.Dokumentationsdatum
Condition.clinicalStatus	Diagnose.KlinscherStatus
Condition.onset[x]	Diagnose.KlinischRelevanterZeitraum
Condition.onsetPeriod	Diagnose.KlinischRelevanterZeitraum.Zeitraum
Condition.onsetPeriod.start	Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am
Condition.onsetPeriod.end	Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis
n.A.	Diagnose.KlinischRelevanterZeitraum.Lebensphase
Condition.onsetPeriod.start.extension:lebensphase-start	Diagnose.KlinischRelevanterZeitraum.Lebensphase.von
Condition.onsetPeriod.end.extension:lebensphase-ende	Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis

FHIR element	Logical dataset
Encounter.period.start	Diagnose.Feststellungsdatum

The invariants of the German Basic Profiles for the data type Profile 'Coding Profile for ICD-10-GM' and the Extension for Diagnostic Certainty must be taken into account.