Beobachtungen, Messungen

Labor

Für die Abbildung von Labordaten in FHIR verweist das TC auf das entsprechende Kerndatensatz-Modul der MI-Initiative https://simplifier.net/medizininformatikinitiative-laborprofile

Diskussion im Chat: https://chat.fhir.org/#narrow/stream/179307-german.2Fmi-initiative

Pflegegrad

Profil

identifierΣ0..*Identifier
basedOnΣ0..*Reference(CarePlan| DeviceRequest| ImmunizationRecommendation| MedicationRequest| NutritionOrder| ServiceRequest)
partOfΣ0..*Reference(MedicationAdministration| MedicationDispense| MedicationStatement| Procedure| Immunization| ImagingStudy)
statusΣ ?!1..1codeBinding
category0..*CodeableConceptBinding
systemΣ1..1uriFixed Value
versionΣ0..1string
codeΣ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectΣ1..1Reference(Patient)
focusΣ0..*Reference(Resource)
encounterΣ0..1Reference(Encounter)
startΣ1..1dateTime
endΣ0..1dateTime
effectivePeriodPeriod
issuedΣ0..1instant
performerΣ0..*Reference(Practitioner| PractitionerRole| Organization| CareTeam| Patient| RelatedPerson)
codingΣ1..*Coding-Profil für OPS
textΣ0..1string
valueCodeableConceptCodeableConcept
dataAbsentReason0..1CodeableConceptBinding
interpretation0..*CodeableConceptBinding
note0..*Annotation
bodySite0..0CodeableConcept
method0..1CodeableConcept
specimen0..1Reference(Specimen)
device0..1Reference(Device| DeviceMetric)
low0..1SimpleQuantity
high0..1SimpleQuantity
type0..1CodeableConceptBinding
appliesTo0..*CodeableConcept
age0..1Range
text0..1string
hasMemberΣ0..*Reference(Observation| QuestionnaireResponse| MolecularSequence)
derivedFromΣ0..*Reference(DocumentReference| ImagingStudy| Media| QuestionnaireResponse| Observation| MolecularSequence)

Beispiel:

<Observation xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/observation-pflegegrad" />
    </meta>
    <status value="final" />
    <code>
        <coding>
            <system value="http://loinc.org" />
            <code value="80391-6" />
            <display value="Pflegegrad" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
    <effectivePeriod>
        <start value="2019-01-09" />
    </effectivePeriod>
    <valueCodeableConcept>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/ops" />
            <version value="2019" />
            <code value="9-984.6" />
            <display value="Pflegebed&#252;rftig nach Pflegegrad 1" />
        </coding>
    </valueCodeableConcept>
</Observation>

Diskussion siehe hier: https://chat.fhir.org/#narrow/stream/179183-german-(d-a-ch)/topic/Observation.20(Pflegestufe)