Description
This profile describes a diagnosis within the Medical Informatics Initiative.
Name | Status | Version | Canonical | Base |
---|---|---|---|---|
MII_PR_Diagnose_Condition | active | 2025.0.0 | https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose | http://hl7.org/fhir/StructureDefinition/Condition |
MII_PR_Diagnose_Condition (Condition) | I | Condition | |
id | S Σ | 0..1 | string |
meta | S Σ | 0..1 | Meta |
id | 0..1 | string | |
extension | I | 0..* | Extension |
versionId | Σ | 0..1 | id |
lastUpdated | Σ | 0..1 | instant |
source | S Σ | 0..1 | uri |
profile | S Σ | 0..* | canonical(StructureDefinition) |
security | Σ | 0..* | CodingBinding |
tag | Σ | 0..* | Coding |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | I | 0..* | Extension |
ReferenzPrimaerdiagnose | S I | 0..1 | Extension(Reference(Condition)) |
Feststellungsdatum | S I | 0..1 | Extension(dateTime) |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
clinicalStatus | S Σ ?! I | 0..1 | CodeableConceptBinding |
verificationStatus | Σ ?! I | 0..1 | CodeableConceptBinding |
category | 0..* | CodeableConceptBinding | |
severity | 0..1 | CodeableConceptBinding | |
code | S Σ | 1..1 | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..* | Coding |
(All Slices) | |||
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 0..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 0..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
icd10-gm | S Σ | 0..1 | CodingICD10GMBindingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
Mehrfachcodierungs-Kennzeichen | I | 0..1 | Extension(Coding) |
Seitenlokalisation | I | 0..1 | Extension(Coding) |
Diagnosesicherheit | I | 0..1 | Extension(Coding) |
system | S Σ | 1..1 | uriFixed ValuePattern |
version | S Σ | 1..1 | string |
code | S Σ I | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
alpha-id | S Σ | 0..1 | CodingAlphaIDBindingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriFixed ValuePattern |
version | Σ | 1..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
sct | S Σ | 0..1 | CodingBindingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | S Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
orphanet | S Σ | 0..1 | CodingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
icd-o-3 | S Σ | 0..1 | CodingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | S Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
bodySite | S Σ | 0..* | CodeableConcept |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..* | Coding |
snomed-ct | S Σ | 1..1 | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | S Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
icd-o-3 | S Σ | 0..1 | Coding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | S Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
subject | S Σ I | 1..1 | MII-Reference(Patient | Group) |
encounter | S Σ I | 0..1 | MII-Reference(Encounter) |
onset[x] | S Σ | 0..1 | |
onsetPeriod | S Σ | 0..1 | Period |
id | 0..1 | string | |
extension | I | 0..* | Extension |
start | S Σ I | 0..1 | dateTime |
id | 0..1 | string | |
extension | I | 0..* | Extension |
lebensphase-von | S I | 0..1 | Extension(CodeableConcept) |
id | 0..1 | string | |
extension | I | 0..* | Extension |
url | 1..1 | uriFixed Value | |
value[x] | 1..1 | ||
valueCodeableConcept | 0..1 | CodeableConcept | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 1..1 | CodingBinding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 1..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
value | 0..1 | System.DateTime | |
end | S Σ I | 0..1 | dateTime |
id | 0..1 | string | |
extension | I | 0..* | Extension |
lebensphase-bis | S I | 0..1 | Extension(CodeableConcept) |
id | 0..1 | string | |
extension | I | 0..* | Extension |
url | 1..1 | uriFixed Value | |
value[x] | 1..1 | ||
valueCodeableConcept | 0..1 | CodeableConcept | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | Σ | 1..1 | CodingBinding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | Σ | 1..1 | uri |
version | Σ | 0..1 | string |
code | Σ | 1..1 | code |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
value | 0..1 | System.DateTime | |
onsetDateTime | S Σ | 0..1 | dateTime |
abatement[x] | I | 0..1 | |
abatementDateTime | dateTime | ||
abatementAge | Age | ||
abatementPeriod | Period | ||
abatementRange | Range | ||
abatementString | string | ||
recordedDate | S Σ | 1..1 | dateTime |
recorder | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
asserter | Σ I | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) |
stage | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
summary | I | 0..1 | CodeableConcept |
assessment | I | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) |
type | 0..1 | CodeableConcept | |
evidence | I | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ I | 0..* | CodeableConcept |
detail | Σ I | 0..* | Reference(Resource) |
note | S | 0..* | Annotation |
Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative |
Fieldname | Shortdescription |
---|---|
Condition.id | |
Condition.meta | |
Condition.meta.source | |
Condition.meta.profile | |
Condition.extension:ReferenzPrimaerdiagnose | |
Condition.extension:Feststellungsdatum | |
Condition.clinicalStatus | |
Condition.code | |
Condition.code.coding | |
Condition.code.coding:icd10-gm | |
Condition.code.coding:icd10-gm.system | |
Condition.code.coding:icd10-gm.version | |
Condition.code.coding:icd10-gm.code | |
Condition.code.coding:alpha-id | |
Condition.code.coding:alpha-id.system | |
Condition.code.coding:alpha-id.code | |
Condition.code.coding:sct | |
Condition.code.coding:sct.system | |
Condition.code.coding:sct.version | |
Condition.code.coding:sct.code | |
Condition.code.coding:orphanet | |
Condition.code.coding:orphanet.system | |
Condition.code.coding:orphanet.code | |
Condition.code.coding:icd-o-3 | ICD-O-3 Morphologie |
Condition.code.coding:icd-o-3.system | |
Condition.code.coding:icd-o-3.version | |
Condition.code.coding:icd-o-3.code | |
Condition.bodySite | |
Condition.bodySite.coding | |
Condition.bodySite.coding:snomed-ct | |
Condition.bodySite.coding:snomed-ct.system | |
Condition.bodySite.coding:snomed-ct.version | |
Condition.bodySite.coding:snomed-ct.code | |
Condition.bodySite.coding:icd-o-3 | ICD-O-3 Topographie |
Condition.bodySite.coding:icd-o-3.system | |
Condition.bodySite.coding:icd-o-3.code | |
Condition.subject | |
Condition.encounter | |
Condition.onset[x] | |
Condition.onset[x]:onsetPeriod | |
Condition.onset[x]:onsetPeriod.start | |
Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von | |
Condition.onset[x]:onsetPeriod.end | |
Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis | |
Condition.onset[x]:onsetDateTime | |
Condition.recordedDate | |
Condition.note |
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="mii-pr-diagnose-condition" /> <url value="https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose" /> <version value="2025.0.0" /> <name value="MII_PR_Diagnose_Condition" /> <title value="MII PR Diagnose Condition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Diagnose" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Diagnosis" /> </extension> </extension> </title> <status value="active" /> <date value="2024-10-15" /> <publisher value="Medizininformatik Initiative" /> <contact> <telecom> <system value="url" /> <value value="https://www.medizininformatik-initiative.de" /> </telecom> </contact> <description value="Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Eine klinische Diagnose der Patientin oder des Patienten." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="A clinical diagnosis of a patient." /> </extension> </extension> </description> <fhirVersion value="4.0.1" /> <mapping> <identity value="LogicalModel" /> <name value="FHIR-Profil zu LogicalModel Mapping" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="Condition" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Condition" /> <derivation value="constraint" /> <differential> <element id="Condition.id"> <path value="Condition.id" /> <mustSupport value="true" /> </element> <element id="Condition.meta"> <path value="Condition.meta" /> <mustSupport value="true" /> </element> <element id="Condition.meta.source"> <path value="Condition.meta.source" /> <mustSupport value="true" /> </element> <element id="Condition.meta.profile"> <path value="Condition.meta.profile" /> <mustSupport value="true" /> </element> <element id="Condition.extension:ReferenzPrimaerdiagnose"> <path value="Condition.extension" /> <sliceName value="ReferenzPrimaerdiagnose" /> <min value="0" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://hl7.org/fhir/StructureDefinition/condition-related" /> </type> <mustSupport value="true" /> </element> <element id="Condition.extension:Feststellungsdatum"> <path value="Condition.extension" /> <sliceName value="Feststellungsdatum" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Feststellungsdatum" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Asserted date" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Datum, an dem die Diagnose erstmals festgestellt wurde" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Date the condition was first asserted" /> </extension> </extension> </definition> <min value="0" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://hl7.org/fhir/StructureDefinition/condition-assertedDate" /> </type> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="Feststellungsdatum" /> </mapping> </element> <element id="Condition.clinicalStatus"> <path value="Condition.clinicalStatus" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Klinischer Status" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Clinical status" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="aktiv | Rezidiv | Rückfall | inaktiv | Remission | abgeklungen" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="active | recurrence | relapse | inactive | remission | resolved" /> </extension> </extension> </definition> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="KlinischerStatus" /> </mapping> </element> <element id="Condition.verificationStatus"> <path value="Condition.verificationStatus" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Verifizierungsstatus" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Verification status" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="unbestätigt | vorläufig | differential | bestätigt | widerlegt | fehlerhafte Eingabe" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="unconfirmed | provisional | differential | confirmed | refuted | entered-in-error" /> </extension> </extension> </definition> </element> <element id="Condition.code"> <path value="Condition.code" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Code" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Code" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Ein ICD-10-, Alpha-ID-, SNOMED-, Orpha- oder anderer Code, der die Diagnose identifiziert." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="An ICD-10-, Alpha-ID-, SNOMED-, Orpha- or other code that identifies the diagnosis." /> </extension> </extension> </definition> <min value="1" /> <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> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="WeitereKodiersysteme" /> </mapping> </element> <element id="Condition.code.coding.code"> <path value="Condition.code.coding.code" /> <mapping> <identity value="LogicalModel" /> <map value="WeitereKodiersysteme.Diagnosecode" /> </mapping> </element> <element id="Condition.code.coding:icd10-gm"> <path value="Condition.code.coding" /> <sliceName value="icd10-gm" /> <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" /> <binding> <strength value="required" /> <valueSet value="http://fhir.de/ValueSet/bfarm/icd-10-gm" /> </binding> <mapping> <identity value="LogicalModel" /> <map value="ICD10GMDiagnoseKodiert" /> </mapping> </element> <element id="Condition.code.coding:icd10-gm.system"> <path value="Condition.code.coding.system" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:icd10-gm.version"> <path value="Condition.code.coding.version" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:icd10-gm.code"> <path value="Condition.code.coding.code" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="ICD10GMDiagnoseKodiert.Diagnosecode" /> </mapping> </element> <element id="Condition.code.coding:alpha-id"> <path value="Condition.code.coding" /> <sliceName value="alpha-id" /> <min value="0" /> <max value="1" /> <type> <code value="Coding" /> <profile value="http://fhir.de/StructureDefinition/CodingAlphaID" /> </type> <patternCoding> <system value="http://fhir.de/CodeSystem/bfarm/alpha-id" /> </patternCoding> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="http://fhir.de/ValueSet/bfarm/alpha-id" /> </binding> <mapping> <identity value="LogicalModel" /> <map value="ALPHAIDKodiert" /> </mapping> </element> <element id="Condition.code.coding:alpha-id.system"> <path value="Condition.code.coding.system" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:alpha-id.code"> <path value="Condition.code.coding.code" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="ALPHAIDKodiert.Diagnosecode" /> </mapping> </element> <element id="Condition.code.coding:sct"> <path value="Condition.code.coding" /> <sliceName value="sct" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://snomed.info/sct" /> </patternCoding> <mustSupport value="true" /> <binding> <strength value="required" /> <valueSet value="https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/ValueSet/diagnoses-sct" /> </binding> <mapping> <identity value="LogicalModel" /> <map value="SNOMEDDiagnoseKodiert" /> </mapping> </element> <element id="Condition.code.coding:sct.system"> <path value="Condition.code.coding.system" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:sct.version"> <path value="Condition.code.coding.version" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:sct.code"> <path value="Condition.code.coding.code" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="SNOMEDDiagnoseKodiert.Diagnosecode" /> </mapping> </element> <element id="Condition.code.coding:orphanet"> <path value="Condition.code.coding" /> <sliceName value="orphanet" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://www.orpha.net" /> </patternCoding> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="ORPHANETDiagnoseKodiert" /> </mapping> </element> <element id="Condition.code.coding:orphanet.system"> <path value="Condition.code.coding.system" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:orphanet.code"> <path value="Condition.code.coding.code" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="ORPHANETDiagnoseKodiert.Diagnosecode" /> </mapping> </element> <element id="Condition.code.coding:icd-o-3"> <path value="Condition.code.coding" /> <sliceName value="icd-o-3" /> <short value="ICD-O-3 Morphologie" /> <min value="0" /> <max value="1" /> <patternCoding> <system value="http://terminology.hl7.org/CodeSystem/icd-o-3" /> </patternCoding> <mustSupport value="true" /> </element> <element id="Condition.code.coding:icd-o-3.system"> <path value="Condition.code.coding.system" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:icd-o-3.version"> <path value="Condition.code.coding.version" /> <mustSupport value="true" /> </element> <element id="Condition.code.coding:icd-o-3.code"> <path value="Condition.code.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.code.text"> <path value="Condition.code.text" /> <mapping> <identity value="LogicalModel" /> <map value="Freitextbeschreibung" /> </mapping> </element> <element id="Condition.bodySite"> <path value="Condition.bodySite" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Körperstelle" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Body site" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Körperstelle der Diagnose mittels SNOMED oder anderem Code." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="The body site of the diagnosis using SNOMED or other systems." /> </extension> </extension> </definition> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="Koerperstelle" /> </mapping> </element> <element id="Condition.bodySite.coding"> <path value="Condition.bodySite.coding" /> <slicing> <discriminator> <type value="pattern" /> <path value="system" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:snomed-ct"> <path value="Condition.bodySite.coding" /> <sliceName value="snomed-ct" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:snomed-ct.system"> <path value="Condition.bodySite.coding.system" /> <min value="1" /> <patternUri value="http://snomed.info/sct" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:snomed-ct.version"> <path value="Condition.bodySite.coding.version" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:snomed-ct.code"> <path value="Condition.bodySite.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:icd-o-3"> <path value="Condition.bodySite.coding" /> <sliceName value="icd-o-3" /> <short value="ICD-O-3 Topographie" /> <min value="0" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:icd-o-3.system"> <path value="Condition.bodySite.coding.system" /> <min value="1" /> <patternUri value="http://terminology.hl7.org/CodeSystem/icd-o-3" /> <mustSupport value="true" /> </element> <element id="Condition.bodySite.coding:icd-o-3.code"> <path value="Condition.bodySite.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="Condition.subject"> <path value="Condition.subject" /> <type> <code value="Reference" /> <profile value="https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Group" /> </type> <mustSupport value="true" /> </element> <element id="Condition.encounter"> <path value="Condition.encounter" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Fall oder Kontakt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Encounter" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Fall oder Kontakt, bei dem die Diagnose festgestellt wurde." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Encounter during which the diagnosis was determined." /> </extension> </extension> </definition> <type> <code value="Reference" /> <profile value="https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Encounter" /> </type> <mustSupport value="true" /> </element> <element id="Condition.onset[x]"> <path value="Condition.onset[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Beginn" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Onset" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Geschätztes oder tatsächliches Datum oder Zeitraum, an dem die Erkrankung begonnen hat, nach Meinung des Klinikers." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Estimated or actual date or date-time the condition began, in the opinion of the clinician." /> </extension> </extension> </definition> <type> <code value="dateTime" /> </type> <type> <code value="Period" /> </type> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum" /> </mapping> </element> <element id="Condition.onset[x]:onsetPeriod"> <path value="Condition.onset[x]" /> <sliceName value="onsetPeriod" /> <min value="0" /> <max value="1" /> <type> <code value="Period" /> </type> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum.Zeitraum" /> </mapping> </element> <element id="Condition.onset[x]:onsetPeriod.start"> <path value="Condition.onset[x].start" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum.Zeitraum.von" /> </mapping> </element> <element id="Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von"> <path value="Condition.onset[x].start.extension" /> <sliceName value="lebensphase-von" /> <min value="0" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://fhir.de/StructureDefinition/lebensphase" /> </type> <mustSupport value="true" /> </element> <element id="Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von.value[x]:valueCodeableConcept"> <path value="Condition.onset[x].start.extension.value[x]" /> <sliceName value="valueCodeableConcept" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum.Lebensphase.von" /> </mapping> </element> <element id="Condition.onset[x]:onsetPeriod.end"> <path value="Condition.onset[x].end" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum.Zeitraum.bis" /> </mapping> </element> <element id="Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis"> <path value="Condition.onset[x].end.extension" /> <sliceName value="lebensphase-bis" /> <min value="0" /> <max value="1" /> <type> <code value="Extension" /> <profile value="http://fhir.de/StructureDefinition/lebensphase" /> </type> <mustSupport value="true" /> </element> <element id="Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis.value[x]:valueCodeableConcept"> <path value="Condition.onset[x].end.extension.value[x]" /> <sliceName value="valueCodeableConcept" /> <type> <code value="CodeableConcept" /> </type> <mapping> <identity value="LogicalModel" /> <map value="KlinischRelevanterZeitraum.Lebensphase.bis" /> </mapping> </element> <element id="Condition.onset[x]:onsetDateTime"> <path value="Condition.onset[x]" /> <sliceName value="onsetDateTime" /> <min value="0" /> <max value="1" /> <type> <code value="dateTime" /> </type> <mustSupport value="true" /> </element> <element id="Condition.recordedDate"> <path value="Condition.recordedDate" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Aufzeichnungsdatum" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Recorded date" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Datum, an dem die Diagnose erstmals dokumentiert wurde." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Date when the diagnosis was first recorded." /> </extension> </extension> </definition> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="Dokumentationsdatum" /> </mapping> </element> <element id="Condition.note"> <path value="Condition.note" /> <short> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Hinweis" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Note" /> </extension> </extension> </short> <definition> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Zusätzliche Informationen zur Diagnose als Freitext." /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="Additional information about the diagnosis as free text." /> </extension> </extension> </definition> <mustSupport value="true" /> <mapping> <identity value="LogicalModel" /> <map value="Diagnoseerlaeuterung" /> </mapping> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "id": "mii-pr-diagnose-condition", "url": "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose", "version": "2025.0.0", "name": "MII_PR_Diagnose_Condition", "title": "MII PR Diagnose Condition", "_title": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Diagnose" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Diagnosis" } ] } ] }, "status": "active", "date": "2024-10-15", "publisher": "Medizininformatik Initiative", "contact": [ { "telecom": [ { "system": "url", "value": "https://www.medizininformatik-initiative.de" } ] } ], "description": "Dieses Profil beschreibt eine Diagnose der Medizininformatik Initiative", "_description": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Eine klinische Diagnose der Patientin oder des Patienten." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "A clinical diagnosis of a patient." } ] } ] }, "fhirVersion": "4.0.1", "mapping": [ { "identity": "LogicalModel", "name": "FHIR-Profil zu LogicalModel Mapping" } ], "kind": "resource", "abstract": false, "type": "Condition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition", "derivation": "constraint", "differential": { "element": [ { "id": "Condition.id", "path": "Condition.id", "mustSupport": true }, { "id": "Condition.meta", "path": "Condition.meta", "mustSupport": true }, { "id": "Condition.meta.source", "path": "Condition.meta.source", "mustSupport": true }, { "id": "Condition.meta.profile", "path": "Condition.meta.profile", "mustSupport": true }, { "id": "Condition.extension:ReferenzPrimaerdiagnose", "path": "Condition.extension", "sliceName": "ReferenzPrimaerdiagnose", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": [ "http://hl7.org/fhir/StructureDefinition/condition-related" ] } ], "mustSupport": true }, { "id": "Condition.extension:Feststellungsdatum", "path": "Condition.extension", "sliceName": "Feststellungsdatum", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": [ "http://hl7.org/fhir/StructureDefinition/condition-assertedDate" ] } ], "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "Feststellungsdatum" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Feststellungsdatum" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Asserted date" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Datum, an dem die Diagnose erstmals festgestellt wurde" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Date the condition was first asserted" } ] } ] } }, { "id": "Condition.clinicalStatus", "path": "Condition.clinicalStatus", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "KlinischerStatus" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Klinischer Status" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Clinical status" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "aktiv | Rezidiv | Rückfall | inaktiv | Remission | abgeklungen" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "active | recurrence | relapse | inactive | remission | resolved" } ] } ] } }, { "id": "Condition.verificationStatus", "path": "Condition.verificationStatus", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Verifizierungsstatus" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Verification status" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "unbestätigt | vorläufig | differential | bestätigt | widerlegt | fehlerhafte Eingabe" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "unconfirmed | provisional | differential | confirmed | refuted | entered-in-error" } ] } ] } }, { "id": "Condition.code", "path": "Condition.code", "min": 1, "mustSupport": true, "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Code" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Code" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Ein ICD-10-, Alpha-ID-, SNOMED-, Orpha- oder anderer Code, der die Diagnose identifiziert." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "An ICD-10-, Alpha-ID-, SNOMED-, Orpha- or other code that identifies the diagnosis." } ] } ] } }, { "id": "Condition.code.coding", "path": "Condition.code.coding", "slicing": { "discriminator": [ { "type": "pattern", "path": "$this" } ], "rules": "open" }, "min": 1, "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "WeitereKodiersysteme" } ] }, { "id": "Condition.code.coding.code", "path": "Condition.code.coding.code", "mapping": [ { "identity": "LogicalModel", "map": "WeitereKodiersysteme.Diagnosecode" } ] }, { "id": "Condition.code.coding:icd10-gm", "path": "Condition.code.coding", "sliceName": "icd10-gm", "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, "binding": { "strength": "required", "valueSet": "http://fhir.de/ValueSet/bfarm/icd-10-gm" }, "mapping": [ { "identity": "LogicalModel", "map": "ICD10GMDiagnoseKodiert" } ] }, { "id": "Condition.code.coding:icd10-gm.system", "path": "Condition.code.coding.system", "mustSupport": true }, { "id": "Condition.code.coding:icd10-gm.version", "path": "Condition.code.coding.version", "mustSupport": true }, { "id": "Condition.code.coding:icd10-gm.code", "path": "Condition.code.coding.code", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "ICD10GMDiagnoseKodiert.Diagnosecode" } ] }, { "id": "Condition.code.coding:alpha-id", "path": "Condition.code.coding", "sliceName": "alpha-id", "min": 0, "max": "1", "type": [ { "code": "Coding", "profile": [ "http://fhir.de/StructureDefinition/CodingAlphaID" ] } ], "patternCoding": { "system": "http://fhir.de/CodeSystem/bfarm/alpha-id" }, "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://fhir.de/ValueSet/bfarm/alpha-id" }, "mapping": [ { "identity": "LogicalModel", "map": "ALPHAIDKodiert" } ] }, { "id": "Condition.code.coding:alpha-id.system", "path": "Condition.code.coding.system", "mustSupport": true }, { "id": "Condition.code.coding:alpha-id.code", "path": "Condition.code.coding.code", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "ALPHAIDKodiert.Diagnosecode" } ] }, { "id": "Condition.code.coding:sct", "path": "Condition.code.coding", "sliceName": "sct", "min": 0, "max": "1", "patternCoding": { "system": "http://snomed.info/sct" }, "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/ValueSet/diagnoses-sct" }, "mapping": [ { "identity": "LogicalModel", "map": "SNOMEDDiagnoseKodiert" } ] }, { "id": "Condition.code.coding:sct.system", "path": "Condition.code.coding.system", "min": 1, "mustSupport": true }, { "id": "Condition.code.coding:sct.version", "path": "Condition.code.coding.version", "mustSupport": true }, { "id": "Condition.code.coding:sct.code", "path": "Condition.code.coding.code", "min": 1, "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "SNOMEDDiagnoseKodiert.Diagnosecode" } ] }, { "id": "Condition.code.coding:orphanet", "path": "Condition.code.coding", "sliceName": "orphanet", "min": 0, "max": "1", "patternCoding": { "system": "http://www.orpha.net" }, "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "ORPHANETDiagnoseKodiert" } ] }, { "id": "Condition.code.coding:orphanet.system", "path": "Condition.code.coding.system", "min": 1, "mustSupport": true }, { "id": "Condition.code.coding:orphanet.code", "path": "Condition.code.coding.code", "min": 1, "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "ORPHANETDiagnoseKodiert.Diagnosecode" } ] }, { "id": "Condition.code.coding:icd-o-3", "path": "Condition.code.coding", "sliceName": "icd-o-3", "short": "ICD-O-3 Morphologie", "min": 0, "max": "1", "patternCoding": { "system": "http://terminology.hl7.org/CodeSystem/icd-o-3" }, "mustSupport": true }, { "id": "Condition.code.coding:icd-o-3.system", "path": "Condition.code.coding.system", "min": 1, "mustSupport": true }, { "id": "Condition.code.coding:icd-o-3.version", "path": "Condition.code.coding.version", "mustSupport": true }, { "id": "Condition.code.coding:icd-o-3.code", "path": "Condition.code.coding.code", "min": 1, "mustSupport": true }, { "id": "Condition.code.text", "path": "Condition.code.text", "mapping": [ { "identity": "LogicalModel", "map": "Freitextbeschreibung" } ] }, { "id": "Condition.bodySite", "path": "Condition.bodySite", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "Koerperstelle" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Körperstelle" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Body site" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Körperstelle der Diagnose mittels SNOMED oder anderem Code." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "The body site of the diagnosis using SNOMED or other systems." } ] } ] } }, { "id": "Condition.bodySite.coding", "path": "Condition.bodySite.coding", "slicing": { "discriminator": [ { "type": "pattern", "path": "system" } ], "rules": "open" }, "min": 1, "mustSupport": true }, { "id": "Condition.bodySite.coding:snomed-ct", "path": "Condition.bodySite.coding", "sliceName": "snomed-ct", "min": 1, "max": "1", "mustSupport": true }, { "id": "Condition.bodySite.coding:snomed-ct.system", "path": "Condition.bodySite.coding.system", "min": 1, "patternUri": "http://snomed.info/sct", "mustSupport": true }, { "id": "Condition.bodySite.coding:snomed-ct.version", "path": "Condition.bodySite.coding.version", "mustSupport": true }, { "id": "Condition.bodySite.coding:snomed-ct.code", "path": "Condition.bodySite.coding.code", "min": 1, "mustSupport": true }, { "id": "Condition.bodySite.coding:icd-o-3", "path": "Condition.bodySite.coding", "sliceName": "icd-o-3", "short": "ICD-O-3 Topographie", "min": 0, "max": "1", "mustSupport": true }, { "id": "Condition.bodySite.coding:icd-o-3.system", "path": "Condition.bodySite.coding.system", "min": 1, "patternUri": "http://terminology.hl7.org/CodeSystem/icd-o-3", "mustSupport": true }, { "id": "Condition.bodySite.coding:icd-o-3.code", "path": "Condition.bodySite.coding.code", "min": 1, "mustSupport": true }, { "id": "Condition.subject", "path": "Condition.subject", "type": [ { "code": "Reference", "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" ], "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group" ] } ], "mustSupport": true }, { "id": "Condition.encounter", "path": "Condition.encounter", "type": [ { "code": "Reference", "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/StructureDefinition/MII-Reference" ], "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter" ] } ], "mustSupport": true, "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Fall oder Kontakt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Encounter" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Fall oder Kontakt, bei dem die Diagnose festgestellt wurde." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Encounter during which the diagnosis was determined." } ] } ] } }, { "id": "Condition.onset[x]", "path": "Condition.onset[x]", "slicing": { "discriminator": [ { "type": "type", "path": "$this" } ], "ordered": false, "rules": "open" }, "type": [ { "code": "dateTime" }, { "code": "Period" } ], "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Beginn" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Onset" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Geschätztes oder tatsächliches Datum oder Zeitraum, an dem die Erkrankung begonnen hat, nach Meinung des Klinikers." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Estimated or actual date or date-time the condition began, in the opinion of the clinician." } ] } ] } }, { "id": "Condition.onset[x]:onsetPeriod", "path": "Condition.onset[x]", "sliceName": "onsetPeriod", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum.Zeitraum" } ] }, { "id": "Condition.onset[x]:onsetPeriod.start", "path": "Condition.onset[x].start", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum.Zeitraum.von" } ] }, { "id": "Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von", "path": "Condition.onset[x].start.extension", "sliceName": "lebensphase-von", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/lebensphase" ] } ], "mustSupport": true }, { "id": "Condition.onset[x]:onsetPeriod.start.extension:lebensphase-von.value[x]:valueCodeableConcept", "path": "Condition.onset[x].start.extension.value[x]", "sliceName": "valueCodeableConcept", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum.Lebensphase.von" } ] }, { "id": "Condition.onset[x]:onsetPeriod.end", "path": "Condition.onset[x].end", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum.Zeitraum.bis" } ] }, { "id": "Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis", "path": "Condition.onset[x].end.extension", "sliceName": "lebensphase-bis", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/lebensphase" ] } ], "mustSupport": true }, { "id": "Condition.onset[x]:onsetPeriod.end.extension:lebensphase-bis.value[x]:valueCodeableConcept", "path": "Condition.onset[x].end.extension.value[x]", "sliceName": "valueCodeableConcept", "type": [ { "code": "CodeableConcept" } ], "mapping": [ { "identity": "LogicalModel", "map": "KlinischRelevanterZeitraum.Lebensphase.bis" } ] }, { "id": "Condition.onset[x]:onsetDateTime", "path": "Condition.onset[x]", "sliceName": "onsetDateTime", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "mustSupport": true }, { "id": "Condition.recordedDate", "path": "Condition.recordedDate", "min": 1, "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "Dokumentationsdatum" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Aufzeichnungsdatum" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Recorded date" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Datum, an dem die Diagnose erstmals dokumentiert wurde." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Date when the diagnosis was first recorded." } ] } ] } }, { "id": "Condition.note", "path": "Condition.note", "mustSupport": true, "mapping": [ { "identity": "LogicalModel", "map": "Diagnoseerlaeuterung" } ], "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Hinweis" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Note" } ] } ] }, "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Zusätzliche Informationen zur Diagnose als Freitext." } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "Additional information about the diagnosis as free text." } ] } ] } } ] } }
FHIR element | Explanation |
---|---|
Condition.id | Must-support, but optional |
Condtion.meta | Must-support, but optional |
Condtion.clinicalStatus | No restrictions, complete diagnostic workflow is supported. The element is optional because it is not recorded routinely. In addition, the status is not usually captured at discharge. |
Condtion.code | Min. 1 coded diagnosis has to be included. System can be selected from Alpha-ID, SNOMED CT, Orpahanet and ICD-10 GM. |
Condtion.code.coding:icd10-gm.extension | Within the extensions "AusrufezeichenCode", "ManifestationsCode" and "Primaercode", the respective code components should be coded without respective special characters (e.g. "!", "+" or "*"). |
Condtion.bodySite | In case this optional element is used, the body site has to be coded at least with one SNOMED-CT code. It is not necessary to specify the laterality here, this should be specified per Condition.code.coding:icd10-gm.extenison:site localization. This field is used to document additional information (beyond the code) about the manifestation. |
Condtion.subject | The reference to the module person is always given. |
Condition.encounter | It should be noted that in most cases this field should not be used to link the case and the diagnosis. This element is used to link the diagnosis to the encounter / contact in which the diagnosis is determined (always a contact with a concrete care center!). In general, the linking should be done via Encounter.diagnosis. |
Condtion.onset[x] | Following the IPS, it can be coded as Period or dateTime. Life phases can additionally be specified if exact times are unknown. |
Condtion.recordedDate | Serves for the chronological classification of the diagnosis (instead of the queries on the initial 'Abteilungsfall' of the determination of the diagnosis). |
Condtion.note | Additional explanation of the diagnosis. |
FHIR element | Explanation |
---|---|
Encounter.period.start / Diagnose.encounter | It should be noted that the mapping of the logical data element "Feststellungsdatum" is not performed on the Condition resource but on the Encounter resource. Thus, the linking of the diagnosis SHOULD always be done to a facility contact (See Case module). |
FHIR Element | Logical dataset |
---|---|
Condition.code:icd-10gm | Diagnose.ICD10GMDiagnoseKodiert |
Condition.code:icd-10gm.coding.code | Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:icd-10gm.coding:extension:Primaercode | Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode |
Condition.code:icd-10gm.coding:extension:ManifestationsCode | Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode |
Condition.code:icd-10gm.coding:extension:AusrufezeichenCode | Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode |
Condition.code:icd-10gm.coding:extension:Diagnosesicherheit | Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit |
Condition.code:icd-10gm.coding:extension:Seitenlokalisation | Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation |
Condition.code:alpha-id | Diagnose.ALPHAIDDiagnoseKodiert |
Condition.code:alpha-id (coding.system, coding.value) | Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:orphanet | Diagnose.ORPHANETDiagnoseKodiert |
Condition.code:orphanet (coding.system, coding.value) | Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code:sct | Diagnose.SNOMEDDiagnoseKodiert |
Condition.code:sct (coding.system, coding.value) | Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode |
Condition.code | Diagnose.WeitereKodiersysteme |
Condition.code (coding.system, coding.value) | Diagnose.WeitereKodesysteme.VollständigerDiagnosecode |
Condition.bodySite | Diagnose.Körperstelle |
Condition.code.text | Diagnose.Freitextbeschreibung |
Condition.note | Diagnose.Diagnoseerläuterung |
Condition.recordedDate | Diagnose.Dokumentationsdatum |
Condition.clinicalStatus | Diagnose.KlinscherStatus |
Condition.onset[x] | Diagnose.KlinischRelevanterZeitraum |
Condition.onsetPeriod | Diagnose.KlinischRelevanterZeitraum.Zeitraum |
Condition.onsetPeriod.start | Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am |
Condition.onsetPeriod.end | Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis |
n.A. | Diagnose.KlinischRelevanterZeitraum.Lebensphase |
Condition.onsetPeriod.start.extension:lebensphase-start | Diagnose.KlinischRelevanterZeitraum.Lebensphase.von |
Condition.onsetPeriod.end.extension:lebensphase-ende | Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis |
FHIR element | Logical dataset |
---|---|
Encounter.period.start | Diagnose.Feststellungsdatum |
The invariants of the German Basic Profiles for the data type Profile 'Coding Profile for ICD-10-GM' and the Extension for Diagnostic Certainty must be taken into account.
Examples
ICD-10-GM & SNOMED CT:
{ "resourceType": "Condition", "id": "mii-exa-diagnose-condition-minimal", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0" ] }, "clinicalStatus": { "coding": [ { "code": "active", "system": "http://terminology.hl7.org/CodeSystem/condition-clinical" } ] }, "code": { "coding": [ { "version": "2020", "code": "S50.0", "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm", "display": "Prellung des Ellenbogens" }, { "code": "91613004", "system": "http://snomed.info/sct", "version": "http://snomed.info/sct/900000000000207008/version/20230731", "display": "Contusion of elbow (disorder)" } ], "text": "Prellung des linken Ellenbogens" }, "subject": { "reference": "Patient/12345" }, "encounter": { "reference": "Encounter/12345" }, "onsetPeriod": { "start": "2020-02-26T12:00:00+01:00", "end": "2020-03-05T13:00:00+01:00" }, "recordedDate": "2020-02-26T12:00:00+01:00" }
ICD-10-GM diagnosis with 'Kreuz-Stern-System' and 'Zusatzkennzeichen':
{ "resourceType": "Condition", "id": "mii-exa-diagnose-mehrfachkodierung-primaercode", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0" ] }, "code": { "coding": [ { "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm", "extension": [ { "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit", "valueCoding": { "code": "G", "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT" } }, { "url": "http://fhir.de/StructureDefinition/seitenlokalisation", "valueCoding": { "code": "L", "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION", "display": "links" } }, { "url": "http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen", "valueCoding": { "code": "†", "system": "http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen" } } ], "code": "A54.4", "version": "2020", "display": "Gonokokkeninfektion des Muskel-Skelett-Systems" }, { "system": "http://fhir.de/CodeSystem/bfarm/alpha-id", "code": "I97525", "version": "2020", "display": "Bursitis gonorrhoica" } ] }, "clinicalStatus": { "coding": [ { "code": "active", "system": "http://terminology.hl7.org/CodeSystem/condition-clinical" } ] }, "verificationStatus": { "coding": [ { "code": "confirmed", "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status" } ] }, "subject": { "reference": "Patient/12345" }, "encounter": { "reference": "Encounter/12345" }, "onsetPeriod": { "start": "2019-09-26T12:45:00+01:00", "end": "2020-03-25T13:00:00+01:00" }, "recordedDate": "2020-01-05T12:53:00+01:00" }
{ "resourceType": "Condition", "id": "mii-exa-diagnose-mehrfachkodierung-sekundaercode", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0" ] }, "code": { "coding": [ { "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm", "extension": [ { "url": "http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen", "valueCoding": { "code": "*", "system": "http://fhir.de/CodeSystem/icd-10-gm-mehrfachcodierungs-kennzeichen" } } ], "code": "M73.04", "version": "2020", "display": "Bursitis gonorrhoica[A54.4] : Hand" } ] }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/condition-related", "valueReference": { "reference": "Condition/mii-exa-diagnose-mehrfachkodierung-primaercode" } } ], "clinicalStatus": { "coding": [ { "code": "active", "system": "http://terminology.hl7.org/CodeSystem/condition-clinical" } ] }, "verificationStatus": { "coding": [ { "code": "confirmed", "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status" } ] }, "subject": { "reference": "Patient/12345" }, "encounter": { "reference": "Encounter/12345" }, "onsetPeriod": { "start": "2019-09-26T12:45:00+01:00", "end": "2020-03-25T13:00:00+01:00" }, "recordedDate": "2020-01-05T12:53:00+01:00" }
Alpha-ID and Orpha-Kennnummer:
{ "resourceType": "Condition", "id": "mii-exa-diagnose-multiple-kodierungen", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose|2024.0.0" ] }, "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/condition-assertedDate", "valueDateTime": "2020-02-13" } ], "clinicalStatus": { "coding": [ { "code": "active", "system": "http://terminology.hl7.org/CodeSystem/condition-clinical" } ] }, "code": { "coding": [ { "version": "2020", "code": "H83.8", "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm", "display": "Sonstige näher bezeichnete Krankheiten des Innenohres" }, { "code": "I125918", "system": "http://fhir.de/CodeSystem/bfarm/alpha-id", "version": "2020" }, { "code": "420402", "system": "http://www.orpha.net", "display": "Bogengangsdehiszenz-Syndrom" } ] }, "subject": { "reference": "Patient/12345" }, "encounter": { "reference": "Encounter/12345" }, "onsetPeriod": { "start": "2020-02-13T16:56:00+01:00" }, "recordedDate": "2020-04-26T12:00:00+01:00" }