Pflegediagnose
Pflegeprobleme, Pflegediagnosen und Pflegephänomene werden als Condition angegeben. Unter code
können die Codesysteme für pflegerische Klassifikationen für pflegerische Probleme genutzt werden.
Condition | I | Condition | There are no (further) constraints on this element Element IdCondition Detailed information about conditions, problems or diagnoses DefinitionA clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
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extension | I | 0..* | Extension | Element IdCondition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. 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. Unordered, Open, by url(Value) Constraints
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due-to | S I | 0..* | Extension(CodeableConceptReference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement)) | Element IdCondition.extension:due-to Causes for this Condition Alternate namesextensions, user content DefinitionFurther conditions, problems, diagnoses, procedures or events or the substance that caused/triggered this Condition. Although a condition may be caused by a substance, this is not intended to be used to record allergies/adverse reactions to substances. Extension(CodeableConceptReference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement)) Extension URLhttp://hl7.org/fhir/StructureDefinition/condition-dueTo Constraints
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdCondition.identifier External Ids for this condition DefinitionBusiness identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server. Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
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clinicalStatus | Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.clinicalStatus active | recurrence | relapse | inactive | remission | resolved DefinitionThe clinical status of the condition. The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. The clinical status of the condition or diagnosis. ConditionClinicalStatusCodes (required)Constraints
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verificationStatus | S Σ ?! I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.verificationStatus unconfirmed | provisional | differential | confirmed | refuted | entered-in-error DefinitionThe verification status to support the clinical status of the condition. 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. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity. The verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required)Constraints
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category | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.category problem-list-item | encounter-diagnosis DefinitionA category assigned to the condition. The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts. A category assigned to the condition. ConditionCategoryCodes (extensible)Constraints
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severity | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdCondition.severity Subjective severity of condition DefinitionA subjective assessment of the severity of the condition as evaluated by the clinician. Coding of the severity with a terminology is preferred, where possible. A subjective assessment of the severity of the condition as evaluated by the clinician. Condition/DiagnosisSeverity (preferred)Constraints
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code | S Σ | 1..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.code Identification of the condition, problem or diagnosis Alternate namestype DefinitionIdentification of the condition, problem or diagnosis. 0..1 to account for primarily narrative only resources. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Identification of the condition or diagnosis. Condition/Problem/DiagnosisCodes (example)Constraints
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bodySite | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.bodySite Anatomical location, if relevant DefinitionThe anatomical location where this condition manifests itself. 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 bodySite. May be a summary code, or a reference to a very precise definition of the location, or both. Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example)Constraints
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subject | Σ I | 1..1 | Reference(Patient | Group) | There are no (further) constraints on this element Element IdCondition.subject Who has the condition? Alternate namespatient DefinitionIndicates the patient or group who the condition record is associated with. Group is typically used for veterinary or public health use cases. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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encounter | Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element IdCondition.encounter Encounter created as part of DefinitionThe Encounter during which this Condition was created or to which the creation of this record is tightly associated. This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. 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".
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onset[x] | Σ | 0..1 | There are no (further) constraints on this element Element IdCondition.onset[x] Estimated or actual date, date-time, or age DefinitionEstimated or actual date or date-time the condition began, in the opinion of the clinician. Age is generally used when the patient reports an age at which the Condition began to occur.
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onsetDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
onsetAge | Age | There are no (further) constraints on this element Data Type | ||
onsetPeriod | Period | There are no (further) constraints on this element Data Type | ||
onsetRange | Range | There are no (further) constraints on this element Data Type | ||
onsetString | string | There are no (further) constraints on this element Data Type | ||
abatement[x] | I | 0..1 | There are no (further) constraints on this element Element IdCondition.abatement[x] When in resolution/remission DefinitionThe 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. 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.
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abatementDateTime | dateTime | There are no (further) constraints on this element Data Type | ||
abatementAge | Age | There are no (further) constraints on this element Data Type | ||
abatementPeriod | Period | There are no (further) constraints on this element Data Type | ||
abatementRange | Range | There are no (further) constraints on this element Data Type | ||
abatementString | string | There are no (further) constraints on this element Data Type | ||
recordedDate | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element IdCondition.recordedDate Date record was first recorded DefinitionThe recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
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recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdCondition.recorder Who recorded the condition DefinitionIndividual who recorded the record and takes responsibility for its content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdCondition.asserter Person who asserts this condition DefinitionIndividual who is making the condition statement. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) Constraints
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stage | I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.stage Stage/grade, usually assessed formally DefinitionClinical stage or grade of a condition. May include formal severity assessments.
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summary | I | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.summary Simple summary (disease specific) DefinitionA simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing condition stages (e.g. Cancer stages). ConditionStage (example)Constraints
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assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | There are no (further) constraints on this element Element IdCondition.stage.assessment Formal record of assessment DefinitionReference to a formal record of the evidence on which the staging assessment is based. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(ClinicalImpression | DiagnosticReport | Observation) Constraints
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type | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdCondition.stage.type Kind of staging DefinitionThe kind of staging, such as pathological or clinical staging. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes describing the kind of condition staging (e.g. clinical or pathological). ConditionStageType (example)Constraints
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evidence | S I | 0..* | BackboneElement | There are no (further) constraints on this element Element IdCondition.evidence Supporting evidence DefinitionSupporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition. The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
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code | Σ I | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdCondition.evidence.code Manifestation/symptom DefinitionA manifestation or symptom that led to the recording of this condition. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe the manifestation or symptoms of a condition. ManifestationAndSymptomCodes (example)Constraints
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdCondition.evidence.detail Supporting information found elsewhere DefinitionLinks to other relevant information, including pathology reports. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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note | 0..* | Annotation | There are no (further) constraints on this element Element IdCondition.note Additional information about the Condition DefinitionAdditional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis. For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible).
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Symptome
Die Symptome, die sich im Kontext des übermittelten Problems zeigen, werden unter evidence
angegeben.
Ätiologie
Die Ätiologie des Pflegeproblems wird in der internationalen Extension due-to
angegeben.
Beispiel mit SNOMED-CT-Code und Extension
<Condition xmlns="http://hl7.org/fhir"> <id value="GeNS_EX_Sprache" /> <meta> <profile value="http://hs-osnabrueck.de/fhir/ePflegebericht/StructureDefinition/NursingProblem" /> </meta> <extension url="http://hl7.org/fhir/StructureDefinition/condition-dueTo"> <valueReference> <reference value="Condition/Hirninfarkt" /> </valueReference> </extension> <code> <coding> <system value="http://snomed.info/sct" /> <code value="162294008" /> <display value="eingeschränkte Sprache" /> </coding> </code> <subject> <reference value="Patient/example" /> </subject> </Condition>
Beispiel mit ICNP-Code
<Condition xmlns="http://hl7.org/fhir"> <id value="GeNS_EX_Selbstpflegedefizit" /> <meta> <profile value="http://hs-osnabrueck.de/fhir/ePflegebericht/StructureDefinition/NursingProblem" /> </meta> <code> <coding> <system value="urn:oid:2.16.840.1.113883.6.97" /> <code value="10023410" /> <display value="Selbstpflegedefizit" /> </coding> </code> <subject> <reference value="Patient/example" /> </subject> </Condition>