MII-Initiative

Medizininformatik Initiative - CORD - Implementierungsleitfaden

Sonstige Befunde

ValueSet 'AdditionalFindings'

Version2023-04-15T13:35:41
Published byBerliner Institut für Gesundheitsforschung / Berlin Institute of Health (BIH)
StatusDraft
ExperimentalFalse

Additional findings

This value set includes codes from the following code systems:

  • The following codes from system: SNOMED_CT

    CodeDisplay
    22166009Skeletal muscle tender (finding)
    7890003Contracture of joint (disorder)
    3434004Myotonia (finding)
    563001Nystagmus (disorder)
  • Include codes from SNOMED_CT where concept IsA 239734000
  • Include codes from SNOMED_CT where concept IsA 239740007

Canonical:https://art-decor.org/fhir/ValueSet/2.16.840.1.113883.3.1937.777.30.11.28--20230415133541

Die sonstigen Befunde werden mit der Ressource Condition abgebildet. Das entwickelte ValueSet wird als Binding an entsprechender Stelle gesetzt. Als Grundprofil soll das Condition-Profil vom GECCO (abgeleitet vom Kerndatensatz der MII) genutzt werden. Im GECCO wurde eine spezielle Extension zur Angabe des Fehlens oder Vorhandensein von Befunden entwickelt (verificationStatus).

idS Σ0..1id
id0..1
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
ReferenzPrimaerdiagnoseS I0..1Extension(Reference(Condition))
uncertaintyOfPresenceS ?! I0..1Extension(CodeableConcept)
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
id0..1
extensionI0..*Extension
id0..1
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1
extensionI0..*Extension
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1
extensionI0..*Extension
id0..1
Mehrfachcodierungs-KennzeichenS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
DiagnosesicherheitS I0..1Extension(Coding)
systemS Σ1..1uriFixed Value
versionS Σ1..1string
codeS Σ I1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1
extensionI0..*Extension
id0..1
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterS Σ I0..1MII-Reference(Encounter)
id0..1
extensionI0..*Extension
id0..1
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1
id0..1
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
id0..1
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation

Folgende Bindings sollen für den ERKER-NMD gesetzt werden

Binding Canonical
Condition.code.coding.sct https://art-decor.org/fhir/ValueSet/2.16.840.1.113883.3.1937.777.30.11.28--20230415133541