Diagnose
Dieses Profil enthält diagnostisch relevante Informationen. Es können entweder Unfallabhängige oder Unfallunabhängige Informationen abgelegt werden.
Alle Extensions sind im Abschnitt Extensions für Condition dokumentiert.
Name: DGUV_Basis_PR_Diagnose Simplifier Projekt Link
Canonical: https://fhir.dguv.de/Basis/Condition/DGUV-Basis-PR-Diagnose
Condition | I | Condition | Element IdCondition Diagnose DefinitionDieses Profil enthält diagnostisch relevante Informationen. Es können entweder Unfallabhängige oder Unfallunabhängige Informationen abgelegt werden.
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meta | Σ | 1..1 | Meta | There are no (further) constraints on this element Element IdCondition.meta Metadata about the resource DefinitionThe 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.
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versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element IdCondition.meta.versionId Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
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lastUpdated | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdCondition.meta.lastUpdated When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.
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source | Σ | 0..1 | uri | There are no (further) constraints on this element Element IdCondition.meta.source Identifies where the resource comes from DefinitionA uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
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profile | Σ | 1..1 | canonical(StructureDefinition)Fixed Value | Element IdCondition.meta.profile Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. canonical(StructureDefinition) Constraints
https://fhir.dguv.de/Basis/Condition/DGUV-Basis-PR-Diagnose|1.0
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security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element IdCondition.meta.security Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element IdCondition.meta.tag Tags applied to this resource DefinitionTags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example)Constraints
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extension | I | 1..1 | Extension | There are no (further) constraints on this element 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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Unfalldiagnose | I | 1..1 | Extension(boolean) | Element IdCondition.extension:Unfalldiagnose Handelt es sich um Unfallabhängige oder Unfallunabhängige Daten? Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. https://fhir.dguv.de/Basis/Extension/DGUV-Basis-EX-Unfalldiagnose 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 | 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 | Σ | 1..1 | CodeableConcept | Element IdCondition.code Identification of the condition, problem or diagnosis Alternate namestype DefinitionIn diesem Element wird der Diagnosecode aufgeführt. Eine ICD-10 Codierung ist an dieser Stelle verpflichtent. 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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coding | Σ | 1..* | Coding | Element IdCondition.code.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Unordered, Open, by code(Value) Constraints
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ICD-10-GM | Σ | 1..1 | Coding-Profil für ICD-10-GM | Element IdCondition.code.coding:ICD-10-GM A reference to a code defined by a terminology system DefinitionIn Deutschland ist der ICD-Code das maßgebliche Code-System für die Abrechnung im ambulanten und stationären Bereich. Allows for alternative encodings within a code system, and translations to other code systems. 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.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.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 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. 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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Mehrfachcodierungs-Kennzeichen | I | 0..1 | Extension(Coding) | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.extension:Mehrfachcodierungs-Kennzeichen Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Constraints
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Seitenlokalisation | I | 0..1 | Extension(Coding) | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.extension:Seitenlokalisation Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/seitenlokalisation Constraints
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Diagnosesicherheit | I | 0..1 | Extension(Coding) | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.extension:Diagnosesicherheit Optional Extensions Element Alternate namesextensions, user content DefinitionOptional Extension Element - found in all resources. 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. http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints
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system | Σ | 1..1 | uriFixed Value | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.system Canonische CodeSystem URL für ICD-10-GM DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. 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.
http://fhir.de/CodeSystem/bfarm/icd-10-gm
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version | Σ | 1..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.version Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") DefinitionBie 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. 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.
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code | Σ I | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.code Der ICD-10-Code DefinitionA 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). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
Einfacher ICD-Code F17.4 Mappings
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display | Σ | 1..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:ICD-10-GM.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). 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. 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.
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snomed | Σ | 0..1 | CodingBinding | Element IdCondition.code.coding:snomed Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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. Dieses Valueset enthält die Codes zur Beschreibung von Diagnose SNOMED KBV_VS_Base_Diagnosis_SNOMED_CT (required)Constraints
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system | Σ | 1..1 | uriFixed Value | Element IdCondition.code.coding:snomed.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. 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.
http://snomed.info/sct
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version | Σ | 1..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:snomed.version Version of the system - if relevant DefinitionThe 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. 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.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:snomed.code Symbol in syntax defined by the system DefinitionA 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). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:snomed.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:snomed.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). 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. 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.
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alphaId | Σ | 0..1 | Coding-Profil für Alpha-ID | Element IdCondition.code.coding:alphaId A reference to a code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
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orphanet | Σ | 0..1 | Coding | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. 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.
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system | Σ | 1..1 | uriFixed Value | Element IdCondition.code.coding:orphanet.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. 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.
http://www.orpha.net
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.version Version of the system - if relevant DefinitionThe 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. 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.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.code Symbol in syntax defined by the system DefinitionA 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). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdCondition.code.coding:orphanet.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). 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. 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.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element IdCondition.code.text Plain text representation of the concept DefinitionA 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. 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. Very often the text is the same as a displayName of one of the codings.
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bodySite | Σ | 0..1 | 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(Versicherte Person) | 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 | D-Arzt(Practitioner | PractitionerRole | Patient | RelatedPerson), Leistungserbringer(Practitioner | PractitionerRole | Patient | RelatedPerson) | 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. D-Arzt(Practitioner | PractitionerRole | Patient | RelatedPerson), Leistungserbringer(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 | 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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Besonderheiten
Der boolescher Wert in der Extension Unfalldiagnose (Extensions für Condition) wird verwendet, um zu unterschieden, ob es sich bei den Diagnosedaten um unfallabhängige oder unfallunabhängige Informationen handelt. Auf diese Weise kann das medizinische Fachpersonal ein umfassenderes Bild der Vorgeschichte des Patienten erhalten und geeignete Diagnosen und Behandlungen vorschlagen. Dieser Wert ist entscheidend für die korrekte Verarbeitung der Daten und muss entsprechend angegeben werden.