MaiaRuleBasedEvaluation (RiskAssessment)

Tiplu presumed diagnoses are generated and displayed based on a set of rules derived from medical guidelines and literature (state-of-the-art medicine).

Customised presumptive diagnoses can be created and released to all MAIA users in the hospital by physicians trained by the manufacturer, known as Medical Administrators, using a rules editor built into MAIA. These function similarly to Tiplu presumed diagnoses, but additionally provide the option to include therapy and diagnostic information. Medical administrators can enable/disable these rules only for patients within the departments for which they have access rights.

German: Tiplu-Verdachtsdiagnosen werden auf der Grundlage eines von Leitlinien und Fachliteratur (State-of-the-Art Medizin) basierenden Regelwerkes generiert und angezeigt.

Vom Hersteller geschulte Ärzte, so genannte Medical Administrators, können mithilfe eines in MAIA integrierten Regeleditors benutzerdefinierte Verdachtsdiagnosen erstellen und für alle MAIA-Benutzer im Krankenhaus freigeben. Diese funktionieren analog zu Tiplu-Verdachtsdiagnosen, bieten jedoch zusätzlich die Möglichkeit, Therapie- und Diagnostikinformationen zu hinterlegen. Medizinische Administrator:innen können dabei entsprechende Hinweise nur für Patient:innen der Fachabteilungen aktivieren/deaktivieren, auf deren Patient:innen sie ein Zugriffsrecht haben.

Metadaten

Canonicalhttps://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation
Statusdraft
Version1.0.0
Basishttp://hl7.org/fhir/StructureDefinition/RiskAssessment

Inhalt

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
id0..1string
extensionI0..*Extension
statusS1..1codeBinding
divS I1..1xhtml
contained0..*Resource
id0..1string
extensionI0..0Extension
url1..1uriFixed Value
valueCodingCoding
id0..1string
extensionI0..0Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayS Σ1..1string
userSelectedΣ0..1boolean
textS Σ0..1string
identifierΣ0..*Identifier
basedOn0..1Reference(Resource)
parent0..1Reference(MaiaRuleBasedEvaluation)
statusS Σ1..1codeBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1codePattern
displayS Σ1..1stringPattern
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uri
versionΣ0..1string
codeS Σ1..1code
displayS Σ1..1string
userSelectedΣ0..1boolean
textS Σ0..1string
id0..1string
extensionI0..*Extension
referenceΣ I0..1string
typeΣ0..1uriBinding
id0..1string
extensionI0..*Extension
useΣ ?!0..1codeBinding
typeS Σ1..1CodeableConceptBindingPattern
systemS Σ1..1uri
valueS Σ1..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
displayΣ0..1string
id0..1string
id0..1string
extensionI0..0Extension
url1..1uriFixed Value
id0..1string
extensionI0..*Extension
useΣ ?!0..1codeBinding
typeS Σ0..1CodeableConceptBinding
systemS Σ0..1uri
valueS Σ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
referenceΣ I0..1string
typeΣ0..1uriBinding
identifierΣ0..1Identifier
displayΣ0..1string
occurrencePeriodPeriod
occurrenceDateTimeS Σ1..1dateTime
conditionΣ0..1Reference(Condition)
performerS Σ1..1Reference(Device)
reasonCode0..*CodeableConcept
reasonReference0..*Reference(Condition | Observation | DiagnosticReport | DocumentReference)
id0..1string
extensionI0..*Extension
referenceS Σ I1..1string
typeS Σ1..1uriBindingPattern
identifierΣ0..1Identifier
displayΣ0..1string
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
outcome0..1CodeableConcept
probabilityDecimaldecimal
probabilityRangeRange
id0..1string
extensionI0..*Extension
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extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayS Σ1..1string
userSelectedΣ0..1boolean
textΣ0..1string
relativeRisk0..1decimal
whenRangeRange
id0..1string
extensionI0..*Extension
startS Σ I1..1dateTime
endS Σ I0..1dateTime
rationaleS0..1string
mitigation0..1string
note0..*Annotation
<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="MaiaRuleBasedEvaluation" />
    <url value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation" />
    <version value="1.0.0" />
    <name value="MaiaRuleBasedEvaluation" />
    <title value="Maia Rule Based Evaluation" />
    <status value="draft" />
    <experimental value="false" />
    <date value="2025-04-30" />
    <publisher value="Tiplu GmbH" />
    <description value="Tiplu presumed diagnoses are generated and displayed based on a set of rules derived from medical guidelines and literature (state-of-the-art medicine). \n\nCustomised presumptive diagnoses can be created and released to all MAIA users in the hospital by physicians trained by the manufacturer, known as Medical Administrators, using a rules editor built into MAIA. These function similarly to Tiplu presumed diagnoses, but additionally provide the option to include therapy and diagnostic information. Medical administrators can enable/disable these rules only for patients within the departments for which they have access rights.\n\n*German:*\nTiplu-Verdachtsdiagnosen werden auf der Grundlage eines von Leitlinien und Fachliteratur (State-of-the-Art Medizin) basierenden Regelwerkes generiert und angezeigt. \n\nVom Hersteller geschulte &#196;rzte, so genannte Medical Administrators, k&#246;nnen mithilfe eines in MAIA integrierten Regeleditors benutzerdefinierte Verdachtsdiagnosen erstellen und f&#252;r alle MAIA-Benutzer im Krankenhaus freigeben. Diese funktionieren analog zu Tiplu-Verdachtsdiagnosen, bieten jedoch zus&#228;tzlich die M&#246;glichkeit, Therapie- und Diagnostikinformationen zu hinterlegen.  Medizinische Administrator:innen k&#246;nnen dabei entsprechende Hinweise nur f&#252;r Patient:innen der Fachabteilungen aktivieren/deaktivieren, auf deren Patient:innen sie ein Zugriffsrecht haben." />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="RiskAssessment" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/RiskAssessment" />
    <derivation value="constraint" />
    <differential>
        <element id="RiskAssessment.text">
            <path value="RiskAssessment.text" />
            <short value="human-readable narrative" />
            <comment value="HTML representation of this rule-based evaluation" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.text.status">
            <path value="RiskAssessment.text.status" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.text.div">
            <path value="RiskAssessment.text.div" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.extension">
            <path value="RiskAssessment.extension" />
            <min value="1" />
        </element>
        <element id="RiskAssessment.extension:ReviewStatus">
            <path value="RiskAssessment.extension" />
            <sliceName value="ReviewStatus" />
            <min value="1" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluationReviewStatus" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.extension:ReviewStatus.value[x]">
            <path value="RiskAssessment.extension.value[x]" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason">
            <path value="RiskAssessment.modifierExtension" />
            <sliceName value="HiddenReason" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaHiddenReason" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x]">
            <path value="RiskAssessment.modifierExtension.value[x]" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason">
            <path value="RiskAssessment.modifierExtension.value[x].coding" />
            <sliceName value="Reason" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.system">
            <path value="RiskAssessment.modifierExtension.value[x].coding.system" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.code">
            <path value="RiskAssessment.modifierExtension.value[x].coding.code" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.display">
            <path value="RiskAssessment.modifierExtension.value[x].coding.display" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.modifierExtension:HiddenReason.value[x].text">
            <path value="RiskAssessment.modifierExtension.value[x].text" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.parent">
            <path value="RiskAssessment.parent" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation" />
            </type>
        </element>
        <element id="RiskAssessment.status">
            <path value="RiskAssessment.status" />
            <short value="Status of the rule-based evaluation" />
            <comment value="Status &#39;preliminary&#39; is default set for rule-based evaluation." />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.method">
            <path value="RiskAssessment.method" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.method.coding">
            <path value="RiskAssessment.method.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.method.coding:AssessmentMethod">
            <path value="RiskAssessment.method.coding" />
            <sliceName value="AssessmentMethod" />
            <short value="Assessment method used for this RiskAssessment" />
            <min value="1" />
            <max value="1" />
            <patternCoding>
                <system value="https://tiplu.de/fhir/maia/CodeSystem/MaiaAssessmentMethod" />
            </patternCoding>
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="https://tiplu.de/fhir/maia/ValueSet/MaiaAssessmentMethodVS" />
            </binding>
        </element>
        <element id="RiskAssessment.method.coding:AssessmentMethod.system">
            <path value="RiskAssessment.method.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.method.coding:AssessmentMethod.code">
            <path value="RiskAssessment.method.coding.code" />
            <min value="1" />
            <patternCode value="TRBE" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.method.coding:AssessmentMethod.display">
            <path value="RiskAssessment.method.coding.display" />
            <min value="1" />
            <patternString value="Tiplu rule-based evaluation" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code">
            <path value="RiskAssessment.code" />
            <definition value="Code of the assessed rule-based evaluation" />
            <min value="1" />
            <constraint>
                <key value="MaiaTrbeCodeOrText" />
                <severity value="error" />
                <human value="A code from MaiaPresumedDiagnosisAssessmentType and a free-text display (code.text) must not be used at the same time." />
                <expression value="code.coding.where(system = &#39;https://tiplu.de/fhir/maia/CodeSystem/MaiaPresumedDiagnosisAssessmentType&#39;).exists() xor code.text.exists()" />
                <source value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation" />
            </constraint>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code.coding">
            <path value="RiskAssessment.code.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code.coding:AssessmentType">
            <path value="RiskAssessment.code.coding" />
            <sliceName value="AssessmentType" />
            <short value="Coding of the Tiplu presumed diagnosis" />
            <min value="0" />
            <max value="1" />
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="https://tiplu.de/fhir/maia/ValueSet/MaiaPresumedDiagnosisAssessmentTypeVS" />
            </binding>
        </element>
        <element id="RiskAssessment.code.coding:AssessmentType.system">
            <path value="RiskAssessment.code.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code.coding:AssessmentType.code">
            <path value="RiskAssessment.code.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code.coding:AssessmentType.display">
            <path value="RiskAssessment.code.coding.display" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.code.text">
            <path value="RiskAssessment.code.text" />
            <short value="Name of the custom presumed diagnosis" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.subject">
            <path value="RiskAssessment.subject" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaPatient" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.subject.identifier">
            <path value="RiskAssessment.subject.identifier" />
            <short value="Patient ID of the referenced patient" />
            <comment value="The MAIA FHIR endpoints don&#39;t have the possibility to get the patient resource. For this, the resource identifier is mandatory." />
            <min value="1" />
            <type>
                <code value="Identifier" />
                <profile value="http://fhir.de/StructureDefinition/identifier-pid" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.subject.identifier.type">
            <path value="RiskAssessment.subject.identifier.type" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.subject.identifier.system">
            <path value="RiskAssessment.subject.identifier.system" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.subject.identifier.value">
            <path value="RiskAssessment.subject.identifier.value" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter">
            <path value="RiskAssessment.encounter" />
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaKontaktGesundheitseinrichtung" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter.extension">
            <path value="RiskAssessment.encounter.extension" />
            <min value="1" />
        </element>
        <element id="RiskAssessment.encounter.extension:AccountIdentifier">
            <path value="RiskAssessment.encounter.extension" />
            <sliceName value="AccountIdentifier" />
            <short value="Account Identifier (German: Fallnummer/Abrechnungsnummer) of the referenced account" />
            <comment value="The MAIA FHIR endpoints don&#39;t have the possibility to get the account or encounter resource. For this, the resource identifier is mandatory." />
            <min value="1" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaAccountIdentifier" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter.extension:AccountIdentifier.value[x]">
            <path value="RiskAssessment.encounter.extension.value[x]" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter.extension:AccountIdentifier.value[x].type">
            <path value="RiskAssessment.encounter.extension.value[x].type" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter.extension:AccountIdentifier.value[x].system">
            <path value="RiskAssessment.encounter.extension.value[x].system" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.encounter.extension:AccountIdentifier.value[x].value">
            <path value="RiskAssessment.encounter.extension.value[x].value" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.occurrence[x]">
            <path value="RiskAssessment.occurrence[x]" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <min value="1" />
        </element>
        <element id="RiskAssessment.occurrence[x]:occurrenceDateTime">
            <path value="RiskAssessment.occurrence[x]" />
            <sliceName value="occurrenceDateTime" />
            <short value="Last calculation of MAIA" />
            <min value="1" />
            <max value="1" />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.performer">
            <path value="RiskAssessment.performer" />
            <comment value="A Device example with valid MAIA information can be found in the Simplifier project." />
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Device" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.basis">
            <path value="RiskAssessment.basis" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <short value="Definition of the rule based presumed diagnoses" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.basis:RiskAssessmentDefinition">
            <path value="RiskAssessment.basis" />
            <sliceName value="RiskAssessmentDefinition" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://tiplu.de/fhir/maia/StructureDefinition/MaiaRiskAssessmentDefinition" />
            </type>
            <patternReference>
                <type value="Basic" />
            </patternReference>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.basis:RiskAssessmentDefinition.reference">
            <path value="RiskAssessment.basis.reference" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.basis:RiskAssessmentDefinition.type">
            <path value="RiskAssessment.basis.type" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction">
            <path value="RiskAssessment.prediction" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.outcome">
            <path value="RiskAssessment.prediction.outcome" />
            <comment value="Beschreiben, warum kein MS und nicht vorhanden TODO" />
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk">
            <path value="RiskAssessment.prediction.qualitativeRisk" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk.coding">
            <path value="RiskAssessment.prediction.qualitativeRisk.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk">
            <path value="RiskAssessment.prediction.qualitativeRisk.coding" />
            <sliceName value="QualitativeRisk" />
            <min value="1" />
            <max value="1" />
            <patternCoding>
                <system value="http://terminology.hl7.org/CodeSystem/risk-probability" />
            </patternCoding>
            <mustSupport value="true" />
            <binding>
                <strength value="required" />
                <valueSet value="http://hl7.org/fhir/ValueSet/risk-probability" />
            </binding>
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.system">
            <path value="RiskAssessment.prediction.qualitativeRisk.coding.system" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.code">
            <path value="RiskAssessment.prediction.qualitativeRisk.coding.code" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.display">
            <path value="RiskAssessment.prediction.qualitativeRisk.coding.display" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.when[x]">
            <path value="RiskAssessment.prediction.when[x]" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <min value="1" />
        </element>
        <element id="RiskAssessment.prediction.when[x]:whenPeriod">
            <path value="RiskAssessment.prediction.when[x]" />
            <sliceName value="whenPeriod" />
            <min value="1" />
            <max value="1" />
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.when[x]:whenPeriod.start">
            <path value="RiskAssessment.prediction.when[x].start" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.when[x]:whenPeriod.end">
            <path value="RiskAssessment.prediction.when[x].end" />
            <mustSupport value="true" />
        </element>
        <element id="RiskAssessment.prediction.rationale">
            <path value="RiskAssessment.prediction.rationale" />
            <short value="Reasoning" />
            <comment value="Provides the patient-specific relevant data points for the result provided by the rule-based evaluation from the patient record if possible." />
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>
{
    "resourceType": "StructureDefinition",
    "id": "MaiaRuleBasedEvaluation",
    "url": "https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation",
    "version": "1.0.0",
    "name": "MaiaRuleBasedEvaluation",
    "title": "Maia Rule Based Evaluation",
    "status": "draft",
    "experimental": false,
    "date": "2025-04-30",
    "publisher": "Tiplu GmbH",
    "description": "Tiplu presumed diagnoses are generated and displayed based on a set of rules derived from medical guidelines and literature (state-of-the-art medicine). \n\nCustomised presumptive diagnoses can be created and released to all MAIA users in the hospital by physicians trained by the manufacturer, known as Medical Administrators, using a rules editor built into MAIA. These function similarly to Tiplu presumed diagnoses, but additionally provide the option to include therapy and diagnostic information. Medical administrators can enable/disable these rules only for patients within the departments for which they have access rights.\n\n*German:*\nTiplu-Verdachtsdiagnosen werden auf der Grundlage eines von Leitlinien und Fachliteratur (State-of-the-Art Medizin) basierenden Regelwerkes generiert und angezeigt. \n\nVom Hersteller geschulte Ärzte, so genannte Medical Administrators, können mithilfe eines in MAIA integrierten Regeleditors benutzerdefinierte Verdachtsdiagnosen erstellen und für alle MAIA-Benutzer im Krankenhaus freigeben. Diese funktionieren analog zu Tiplu-Verdachtsdiagnosen, bieten jedoch zusätzlich die Möglichkeit, Therapie- und Diagnostikinformationen zu hinterlegen.  Medizinische Administrator:innen können dabei entsprechende Hinweise nur für Patient:innen der Fachabteilungen aktivieren/deaktivieren, auf deren Patient:innen sie ein Zugriffsrecht haben.",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "RiskAssessment",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/RiskAssessment",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "RiskAssessment.text",
                "path": "RiskAssessment.text",
                "short": "human-readable narrative",
                "comment": "HTML representation of this rule-based evaluation",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.text.status",
                "path": "RiskAssessment.text.status",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.text.div",
                "path": "RiskAssessment.text.div",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.extension",
                "path": "RiskAssessment.extension",
                "min": 1
            },
            {
                "id": "RiskAssessment.extension:ReviewStatus",
                "path": "RiskAssessment.extension",
                "sliceName": "ReviewStatus",
                "min": 1,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluationReviewStatus"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.extension:ReviewStatus.value[x]",
                "path": "RiskAssessment.extension.value[x]",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason",
                "path": "RiskAssessment.modifierExtension",
                "sliceName": "HiddenReason",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaHiddenReason"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x]",
                "path": "RiskAssessment.modifierExtension.value[x]",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason",
                "path": "RiskAssessment.modifierExtension.value[x].coding",
                "sliceName": "Reason",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.system",
                "path": "RiskAssessment.modifierExtension.value[x].coding.system",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.code",
                "path": "RiskAssessment.modifierExtension.value[x].coding.code",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x].coding:Reason.display",
                "path": "RiskAssessment.modifierExtension.value[x].coding.display",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.modifierExtension:HiddenReason.value[x].text",
                "path": "RiskAssessment.modifierExtension.value[x].text",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.parent",
                "path": "RiskAssessment.parent",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation"
                        ]
                    }
                ]
            },
            {
                "id": "RiskAssessment.status",
                "path": "RiskAssessment.status",
                "short": "Status of the rule-based evaluation",
                "comment": "Status 'preliminary' is default set for rule-based evaluation.",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.method",
                "path": "RiskAssessment.method",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.method.coding",
                "path": "RiskAssessment.method.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.method.coding:AssessmentMethod",
                "path": "RiskAssessment.method.coding",
                "sliceName": "AssessmentMethod",
                "short": "Assessment method used for this RiskAssessment",
                "min": 1,
                "max": "1",
                "patternCoding": {
                    "system": "https://tiplu.de/fhir/maia/CodeSystem/MaiaAssessmentMethod"
                },
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "https://tiplu.de/fhir/maia/ValueSet/MaiaAssessmentMethodVS"
                }
            },
            {
                "id": "RiskAssessment.method.coding:AssessmentMethod.system",
                "path": "RiskAssessment.method.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.method.coding:AssessmentMethod.code",
                "path": "RiskAssessment.method.coding.code",
                "min": 1,
                "patternCode": "TRBE",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.method.coding:AssessmentMethod.display",
                "path": "RiskAssessment.method.coding.display",
                "min": 1,
                "patternString": "Tiplu rule-based evaluation",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code",
                "path": "RiskAssessment.code",
                "definition": "Code of the assessed rule-based evaluation",
                "min": 1,
                "constraint":  [
                    {
                        "key": "MaiaTrbeCodeOrText",
                        "severity": "error",
                        "human": "A code from MaiaPresumedDiagnosisAssessmentType and a free-text display (code.text) must not be used at the same time.",
                        "expression": "code.coding.where(system = 'https://tiplu.de/fhir/maia/CodeSystem/MaiaPresumedDiagnosisAssessmentType').exists() xor code.text.exists()",
                        "source": "https://tiplu.de/fhir/maia/StructureDefinition/MaiaRuleBasedEvaluation"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code.coding",
                "path": "RiskAssessment.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code.coding:AssessmentType",
                "path": "RiskAssessment.code.coding",
                "sliceName": "AssessmentType",
                "short": "Coding of the Tiplu presumed diagnosis",
                "min": 0,
                "max": "1",
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "https://tiplu.de/fhir/maia/ValueSet/MaiaPresumedDiagnosisAssessmentTypeVS"
                }
            },
            {
                "id": "RiskAssessment.code.coding:AssessmentType.system",
                "path": "RiskAssessment.code.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code.coding:AssessmentType.code",
                "path": "RiskAssessment.code.coding.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code.coding:AssessmentType.display",
                "path": "RiskAssessment.code.coding.display",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.code.text",
                "path": "RiskAssessment.code.text",
                "short": "Name of the custom presumed diagnosis",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.subject",
                "path": "RiskAssessment.subject",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaPatient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.subject.identifier",
                "path": "RiskAssessment.subject.identifier",
                "short": "Patient ID of the referenced patient",
                "comment": "The MAIA FHIR endpoints don't have the possibility to get the patient resource. For this, the resource identifier is mandatory.",
                "min": 1,
                "type":  [
                    {
                        "code": "Identifier",
                        "profile":  [
                            "http://fhir.de/StructureDefinition/identifier-pid"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.subject.identifier.type",
                "path": "RiskAssessment.subject.identifier.type",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.subject.identifier.system",
                "path": "RiskAssessment.subject.identifier.system",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.subject.identifier.value",
                "path": "RiskAssessment.subject.identifier.value",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter",
                "path": "RiskAssessment.encounter",
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaKontaktGesundheitseinrichtung"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter.extension",
                "path": "RiskAssessment.encounter.extension",
                "min": 1
            },
            {
                "id": "RiskAssessment.encounter.extension:AccountIdentifier",
                "path": "RiskAssessment.encounter.extension",
                "sliceName": "AccountIdentifier",
                "short": "Account Identifier (German: Fallnummer/Abrechnungsnummer) of the referenced account",
                "comment": "The MAIA FHIR endpoints don't have the possibility to get the account or encounter resource. For this, the resource identifier is mandatory.",
                "min": 1,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaAccountIdentifier"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter.extension:AccountIdentifier.value[x]",
                "path": "RiskAssessment.encounter.extension.value[x]",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter.extension:AccountIdentifier.value[x].type",
                "path": "RiskAssessment.encounter.extension.value[x].type",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter.extension:AccountIdentifier.value[x].system",
                "path": "RiskAssessment.encounter.extension.value[x].system",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.encounter.extension:AccountIdentifier.value[x].value",
                "path": "RiskAssessment.encounter.extension.value[x].value",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.occurrence[x]",
                "path": "RiskAssessment.occurrence[x]",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                },
                "min": 1
            },
            {
                "id": "RiskAssessment.occurrence[x]:occurrenceDateTime",
                "path": "RiskAssessment.occurrence[x]",
                "sliceName": "occurrenceDateTime",
                "short": "Last calculation of MAIA",
                "min": 1,
                "max": "1",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.performer",
                "path": "RiskAssessment.performer",
                "comment": "A Device example with valid MAIA information can be found in the Simplifier project.",
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Device"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.basis",
                "path": "RiskAssessment.basis",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "short": "Definition of the rule based presumed diagnoses",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.basis:RiskAssessmentDefinition",
                "path": "RiskAssessment.basis",
                "sliceName": "RiskAssessmentDefinition",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://tiplu.de/fhir/maia/StructureDefinition/MaiaRiskAssessmentDefinition"
                        ]
                    }
                ],
                "patternReference": {
                    "type": "Basic"
                },
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.basis:RiskAssessmentDefinition.reference",
                "path": "RiskAssessment.basis.reference",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.basis:RiskAssessmentDefinition.type",
                "path": "RiskAssessment.basis.type",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction",
                "path": "RiskAssessment.prediction",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.outcome",
                "path": "RiskAssessment.prediction.outcome",
                "comment": "Beschreiben, warum kein MS und nicht vorhanden TODO"
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk",
                "path": "RiskAssessment.prediction.qualitativeRisk",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk.coding",
                "path": "RiskAssessment.prediction.qualitativeRisk.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk",
                "path": "RiskAssessment.prediction.qualitativeRisk.coding",
                "sliceName": "QualitativeRisk",
                "min": 1,
                "max": "1",
                "patternCoding": {
                    "system": "http://terminology.hl7.org/CodeSystem/risk-probability"
                },
                "mustSupport": true,
                "binding": {
                    "strength": "required",
                    "valueSet": "http://hl7.org/fhir/ValueSet/risk-probability"
                }
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.system",
                "path": "RiskAssessment.prediction.qualitativeRisk.coding.system",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.code",
                "path": "RiskAssessment.prediction.qualitativeRisk.coding.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRisk.display",
                "path": "RiskAssessment.prediction.qualitativeRisk.coding.display",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.when[x]",
                "path": "RiskAssessment.prediction.when[x]",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                },
                "min": 1
            },
            {
                "id": "RiskAssessment.prediction.when[x]:whenPeriod",
                "path": "RiskAssessment.prediction.when[x]",
                "sliceName": "whenPeriod",
                "min": 1,
                "max": "1",
                "type":  [
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.when[x]:whenPeriod.start",
                "path": "RiskAssessment.prediction.when[x].start",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.when[x]:whenPeriod.end",
                "path": "RiskAssessment.prediction.when[x].end",
                "mustSupport": true
            },
            {
                "id": "RiskAssessment.prediction.rationale",
                "path": "RiskAssessment.prediction.rationale",
                "short": "Reasoning",
                "comment": "Provides the patient-specific relevant data points for the result provided by the rule-based evaluation from the patient record if possible.",
                "mustSupport": true
            }
        ]
    }
}

Constraints/Invarianten

NameSchweregradBeschreibungAusdruck
MaiaTrbeCodeOrTexterrorA code from MaiaPresumedDiagnosisAssessmentType and a free-text display (code.text) must not be used at the same time.code.coding.where(system = 'https://tiplu.de/fhir/maia/CodeSystem/MaiaPresumedDiagnosisAssessmentType').exists() xor code.text.exists()

Terminology-Bindings

ElementStaerkeValueSet
RiskAssessment.method.coding:AssessmentMethodrequiredhttps://tiplu.de/fhir/maia/ValueSet/MaiaAssessmentMethodVS
RiskAssessment.code.coding:AssessmentTyperequiredhttps://tiplu.de/fhir/maia/ValueSet/MaiaPresumedDiagnosisAssessmentTypeVS
RiskAssessment.prediction.qualitativeRisk.coding:QualitativeRiskrequiredhttp://hl7.org/fhir/ValueSet/risk-probability

Notes on Must-Support fields

FeldnameKurzbeschreibungHinweise
RiskAssessment.texthuman-readable narrative

HTML representation of this rule-based evaluation

RiskAssessment.statusStatus of the rule-based evaluation

Status 'preliminary' is default set for rule-based evaluation.

RiskAssessment.method.coding:AssessmentMethodAssessment method used for this RiskAssessment
RiskAssessment.code.coding:AssessmentTypeCoding of the Tiplu presumed diagnosis
RiskAssessment.code.textName of the custom presumed diagnosis
RiskAssessment.subject.identifierPatient ID of the referenced patient

The MAIA FHIR endpoints don't have the possibility to get the patient resource. For this, the resource identifier is mandatory.

RiskAssessment.encounter.extension:AccountIdentifierAccount Identifier (German: Fallnummer/Abrechnungsnummer) of the referenced account

The MAIA FHIR endpoints don't have the possibility to get the account or encounter resource. For this, the resource identifier is mandatory.

RiskAssessment.occurrence[x]:occurrenceDateTimeLast calculation of MAIA
RiskAssessment.basisDefinition of the rule based presumed diagnoses
RiskAssessment.prediction.rationaleReasoning

Provides the patient-specific relevant data points for the result provided by the rule-based evaluation from the patient record if possible.