Implementierungsleitfaden E-Rechnung

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Anmerkungen zu Must-Support Elementen

ERGRechnungsdiagnose (Condition)

ERGRechnungsdiagnose (Condition)

ERG Rechnungsdiagnose

Bestätigungsrelevanz

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Metadaten

Canonical	https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsdiagnose
Status	active
Version	1.1.0-RC1
Basis	http://hl7.org/fhir/StructureDefinition/Condition

Inhalt

ERGRechnungsdiagnose (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 con-3: Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item `clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()` con-4: If condition is abated, then clinicalStatus must be either inactive, resolved, or remission `abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()` con-5: Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error `verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()` dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).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-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event sct-concept: < 243796009 \|Situation with explicit context\| : 246090004 \|Associated finding\| = ( ( < 404684003 \|Clinical finding\| MINUS ( << 420134006 \|Propensity to adverse reactions\| OR << 473010000 \|Hypersensitivity condition\| OR << 79899007 \|Drug interaction\| OR << 69449002 \|Drug action\| OR << 441742003 \|Evaluation finding\| OR << 307824009 \|Administrative status\| OR << 385356007 \|Tumor stage finding\|)) OR < 272379006 \|Event\|) v2: PPR message rim: Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
id	Σ	0..1	string	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 string
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 might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. 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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
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. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		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 can 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 information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element 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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` 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 Business 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. Requirements Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers. Comments 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. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.identifier w5: FiveWs.identifier rim: .id
clinicalStatus	Σ ?! I	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Condition.clinicalStatus Short description active \| recurrence \| relapse \| inactive \| remission \| resolved Definition The clinical status of the condition. Comments 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. Data type CodeableConcept Binding The clinical status of the condition or diagnosis. ConditionClinicalStatusCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status sct-concept: < 303105007 \|Disease phases\| v2: PRB-14 rim: Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
verificationStatus	Σ ?! I	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Condition.verificationStatus Short description unconfirmed \| provisional \| differential \| confirmed \| refuted \| entered-in-error 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. 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. Data type CodeableConcept Binding The verification status to support or decline the clinical status of the condition or diagnosis. ConditionVerificationStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status 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
category		0..*	CodeableConceptBinding	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. ConditionCategoryCodes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class sct-concept: < 404684003 \|Clinical finding\| v2: 'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message rim: .code
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/DiagnosisSeverity (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.grade 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
code	S 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/DiagnosisCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.code w5: FiveWs.what[x] 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
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.id Short description Unique id for inter-element referencing 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	I	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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
coding	S 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 alternative encodings within a code system, and translations to other code systems. 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 $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
ICD-10-GM	S Σ	0..1	CodingICD10GMPattern	Element id Condition.code.coding:ICD-10-GM Short description Code und Text nach ICD-10 Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments Die Codierung nach ICD-10 SOLL vorhanden sein. Data type CodingICD10GM Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm" } Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.id Short description Unique id for inter-element referencing 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	I	0..*	Extension	There are no (further) constraints on this element 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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
Mehrfachcodierungs-Kennzeichen	I	0..1	Extension(Coding)	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Mehrfachcodierungs-Kennzeichen Short description Optional Extensions Element 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(Coding) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (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
Seitenlokalisation	S I	0..1	Extension(Coding)	Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation Short description Lokalisierung Alternate names extensions, user content Definition Optional Extension Element - found in all resources. Comments Die Lokalisierung SOLL vorhanden sein. Data type Extension(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (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
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.id Short description Unique id for inter-element referencing 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	I	0..0	Extension	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension: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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
url		1..1	uriFixed Value	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.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://fhir.de/StructureDefinition/seitenlokalisation Mappings rim: N/A
value[x]	S	1..1	Binding	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Binding https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
valueCoding			Coding	There are no (further) constraints on this element Data type Coding
id		0..1	string	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].id Short description Unique id for inter-element referencing 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	I	0..*	Extension	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
system	S Σ	1..1	uri	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].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 reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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.extension:Seitenlokalisation.value[x].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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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.extension:Seitenlokalisation.value[x].userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 ]
Diagnosesicherheit	I	0..1	Extension(Coding)	There are no (further) constraints on this element Element id Condition.code.coding:ICD-10-GM.extension:Diagnosesicherheit Short description Optional Extensions Element 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(Coding) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (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	S Σ	1..1	uriFixed ValuePattern	Element id Condition.code.coding:ICD-10-GM.system Short description System des ICD-10 Code 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 Das System des ICD-10 Code MUSS vorhanden sein. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Fixed value http://fhir.de/CodeSystem/bfarm/icd-10-gm Mappings v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	1..1	string	There are no (further) constraints on this element 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ I	1..1	code	Element id Condition.code.coding:ICD-10-GM.code Short description Code nach ICD-10 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. Comments Der Code nach ICD-10 SOLL vorhanden sein. Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` icd-regex: In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt `matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')` Examples Einfacher ICD-Code F17.4 Mappings v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	S Σ	0..1	string	Element id Condition.code.coding:ICD-10-GM.display Short description Text zum ICD-10 Code 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. Comments Der Text zum ICD-10 Code SOLL vorhanden sein. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 - e.g. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 bodySite. 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. SNOMEDCTBodyStructures (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings sct-concept: < 442083009 \|Anatomical or acquired body structure\| rim: .targetBodySiteCode sct-attr: 363698007
subject	S Σ	1..1	Reference(ERGPatient \| Patient)	Element id Condition.subject Short description Referenz auf die behandelte Person 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. Comments Die Diagnose SOLL auf eine zugehörige behandelte Person referenzieren. Data type Reference(ERGPatient \| Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 rim: .participation[typeCode=SBJ].role[classCode=PAT] w5: FiveWs.subject
id		0..1	string	There are no (further) constraints on this element Element id Condition.subject.id Short description Unique id for inter-element referencing 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	I	0..*	Extension	There are no (further) constraints on this element Element id Condition.subject.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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
reference	S Σ I	1..1	string	There are no (further) constraints on this element Element id Condition.subject.reference Short description Literal reference, Relative, internal or absolute URL Definition A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Comments Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
type	Σ	0..1	uriBinding	There are no (further) constraints on this element Element id Condition.subject.type Short description Type the reference refers to (e.g. "Patient") Definition The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). Comments This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Data type uri Binding Aa resource (or, for logical models, the URI of the logical model). ResourceType (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id Condition.subject.identifier Short description Logical reference, when literal reference is not known Definition An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. Comments When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation\|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .identifier
display	Σ	0..1	string	There are no (further) constraints on this element Element id Condition.subject.display Short description Text alternative for the resource Definition Plain text narrative that identifies the resource in addition to the resource reference. Comments This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: N/A
encounter	Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id Condition.encounter Short description Encounter created as part of Definition The Encounter during which this Condition was created or to which the creation of this record is tightly associated. Comments 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". Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.context w5: FiveWs.context v2: PV1-19 (+PV1-54) rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
onset[x]	S Σ	0..1		Element id Condition.onset[x] Short description Behandlungsdatum (Erstdiagnose) Definition Estimated or actual date or date-time the condition began, in the opinion of the clinician. Comments Das Behandlungsdatum (Erstdiagnose) SOLL vorhanden sein. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.init v2: PRB-16 rim: .effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
onsetDateTime			dateTime	Data type dateTime
abatement[x]	I	0..1		There are no (further) constraints on this element Element id Condition.abatement[x] Short description 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. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.done[x] 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
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
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
recordedDate	Σ	0..1	dateTime	There are no (further) constraints on this element Element id Condition.recordedDate Short description Date record was first recorded Definition The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.recorded v2: REL-11 rim: .participation[typeCode=AUT].time
recorder	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element id Condition.recorder Short description Who recorded the condition Definition Individual who recorded the record and takes responsibility for its content. Data type Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.author rim: .participation[typeCode=AUT].role
asserter	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element id Condition.asserter Short description Person who asserts this condition Definition Individual who is making the condition statement. Data type Reference(Practitioner \| PractitionerRole \| Patient \| RelatedPerson) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.source v2: REL-7.1 identifier + REL-7.12 type code rim: .participation[typeCode=INF].role
stage	I	0..*	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 con-1: Stage SHALL have summary or assessment `summary.exists() or assessment.exists()` ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 Unique id for inter-element referencing 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	I	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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Condition.stage.modifierExtension Short description Extensions that cannot be ignored even if unrecognized 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` 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). ConditionStage (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .self
type		0..1	CodeableConcept	There are no (further) constraints on this element Element id Condition.stage.type Short description Kind of staging Definition The kind of staging, such as pathological or clinical staging. Data type CodeableConcept Binding Codes describing the kind of condition staging (e.g. clinical or pathological). ConditionStageType (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]
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 of the Condition's verification status, such as evidence that confirmed or refuted the condition. 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 con-2: evidence SHALL have code or details `code.exists() or detail.exists()` ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` 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 Unique id for inter-element referencing 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	I	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. 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. 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Condition.evidence.modifierExtension Short description Extensions that cannot be ignored even if unrecognized 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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of 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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` 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. ManifestationAndSymptomCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.reasonCode w5: FiveWs.why[x] sct-concept: < 404684003 \|Clinical finding\| rim: [code="diagnosis"].value
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) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.why[x] rim: .self
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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.note v2: NTE child of PRB rim: .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="erg-rechnungsdiagnose" />
    <url value="https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsdiagnose" />
    <version value="1.1.0-RC1" />
    <name value="ERGRechnungsdiagnose" />
    <title value="ERG Rechnungsdiagnose" />
    <status value="active" />
    <experimental value="false" />
    <date value="2025-02-28" />
    <publisher value="gematik GmbH" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="http://gematik.de/" />
        </telecom>
    </contact>
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="Condition" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Condition" />
    <derivation value="constraint" />
    <differential>
        <element id="Condition.code">
            <path value="Condition.code" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding">
            <path value="Condition.code.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM">
            <path value="Condition.code.coding" />
            <sliceName value="ICD-10-GM" />
            <short value="Code und Text nach ICD-10" />
            <comment value="Die Codierung nach ICD-10 SOLL vorhanden sein." />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Coding" />
                <profile value="http://fhir.de/StructureDefinition/CodingICD10GM" />
            </type>
            <patternCoding>
                <system value="http://fhir.de/CodeSystem/bfarm/icd-10-gm" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation">
            <path value="Condition.code.coding.extension" />
            <sliceName value="Seitenlokalisation" />
            <short value="Lokalisierung" />
            <comment value="Die Lokalisierung SOLL vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x]">
            <path value="Condition.code.coding.extension.value[x]" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].system">
            <path value="Condition.code.coding.extension.value[x].system" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].code">
            <path value="Condition.code.coding.extension.value[x].code" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.system">
            <path value="Condition.code.coding.system" />
            <short value="System des ICD-10 Code" />
            <comment value="Das System des ICD-10 Code MUSS vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.code">
            <path value="Condition.code.coding.code" />
            <short value="Code nach ICD-10" />
            <comment value="Der Code nach ICD-10 SOLL vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Condition.code.coding:ICD-10-GM.display">
            <path value="Condition.code.coding.display" />
            <short value="Text zum ICD-10 Code" />
            <comment value="Der Text zum ICD-10 Code SOLL vorhanden sein." />
            <mustSupport value="true" />
        </element>
        <element id="Condition.subject">
            <path value="Condition.subject" />
            <short value="Referenz auf die behandelte Person" />
            <comment value="Die Diagnose SOLL auf eine zugeh&#246;rige behandelte Person referenzieren." />
            <type>
                <code value="Reference" />
                <targetProfile value="https://gematik.de/fhir/erg/StructureDefinition/erg-patient" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Condition.subject.reference">
            <path value="Condition.subject.reference" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="Condition.onset[x]">
            <path value="Condition.onset[x]" />
            <short value="Behandlungsdatum (Erstdiagnose)" />
            <comment value="Das Behandlungsdatum (Erstdiagnose) SOLL vorhanden sein." />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "erg-rechnungsdiagnose",
    "url": "https://gematik.de/fhir/erg/StructureDefinition/erg-rechnungsdiagnose",
    "version": "1.1.0-RC1",
    "name": "ERGRechnungsdiagnose",
    "title": "ERG Rechnungsdiagnose",
    "status": "active",
    "experimental": false,
    "date": "2025-02-28",
    "publisher": "gematik GmbH",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "http://gematik.de/"
                }
            ]
        }
    ],
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Condition",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Condition.code",
                "path": "Condition.code",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding",
                "path": "Condition.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM",
                "path": "Condition.code.coding",
                "sliceName": "ICD-10-GM",
                "short": "Code und Text nach ICD-10",
                "comment": "Die Codierung nach ICD-10 SOLL vorhanden sein.",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Coding",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/CodingICD10GM"
                        ]
                    }
                ],
                "patternCoding": {
                    "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm"
                },
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation",
                "path": "Condition.code.coding.extension",
                "sliceName": "Seitenlokalisation",
                "short": "Lokalisierung",
                "comment": "Die Lokalisierung SOLL vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x]",
                "path": "Condition.code.coding.extension.value[x]",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].system",
                "path": "Condition.code.coding.extension.value[x].system",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].code",
                "path": "Condition.code.coding.extension.value[x].code",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.system",
                "path": "Condition.code.coding.system",
                "short": "System des ICD-10 Code",
                "comment": "Das System des ICD-10 Code MUSS vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.code",
                "path": "Condition.code.coding.code",
                "short": "Code nach ICD-10",
                "comment": "Der Code nach ICD-10 SOLL vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Condition.code.coding:ICD-10-GM.display",
                "path": "Condition.code.coding.display",
                "short": "Text zum ICD-10 Code",
                "comment": "Der Text zum ICD-10 Code SOLL vorhanden sein.",
                "mustSupport": true
            },
            {
                "id": "Condition.subject",
                "path": "Condition.subject",
                "short": "Referenz auf die behandelte Person",
                "comment": "Die Diagnose SOLL auf eine zugehörige behandelte Person referenzieren.",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://gematik.de/fhir/erg/StructureDefinition/erg-patient",
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Condition.subject.reference",
                "path": "Condition.subject.reference",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "Condition.onset[x]",
                "path": "Condition.onset[x]",
                "short": "Behandlungsdatum (Erstdiagnose)",
                "comment": "Das Behandlungsdatum (Erstdiagnose) SOLL vorhanden sein.",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            }
        ]
    }
}

ERG Rechnungsdiagnose

Constraints/Invarianten

Terminology-Bindings

Anmerkungen zu Must-Support-Feldern

Feldname	Kurzbeschreibung	Hinweise
Condition.code
Condition.code.coding
Condition.code.coding:ICD-10-GM	Code und Text nach ICD-10	Die Codierung nach ICD-10 SOLL vorhanden sein.
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation	Lokalisierung	Die Lokalisierung SOLL vorhanden sein.
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x]
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].system
Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation.value[x].code
Condition.code.coding:ICD-10-GM.system	System des ICD-10 Code	Das System des ICD-10 Code MUSS vorhanden sein.
Condition.code.coding:ICD-10-GM.code	Code nach ICD-10	Der Code nach ICD-10 SOLL vorhanden sein.
Condition.code.coding:ICD-10-GM.display	Text zum ICD-10 Code	Der Text zum ICD-10 Code SOLL vorhanden sein.
Condition.subject	Referenz auf die behandelte Person	Die Diagnose SOLL auf eine zugehörige behandelte Person referenzieren.
Condition.subject.reference
Condition.onset[x]	Behandlungsdatum (Erstdiagnose)	Das Behandlungsdatum (Erstdiagnose) SOLL vorhanden sein.