The official and accepted version of the information model for the DIAGNOSE module can be found on ART-DECOR. To standardize the representation, the information model was also modeled as FHIR Logical Model:
MII_LM_Diagnose (Diagnose) | Element | Element idDiagnose Das Basismodul Diagnosen enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc. DefinitionLogische Repräsentation des Basismoduls Diagnose
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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ICD10GMDiagnoseKodiert | 0..1 | BackboneElement | Element idDiagnose.ICD10GMDiagnoseKodiert Im Bereich der administrativen und statistischen Auswertung wird die Diagnose mit Hilfe von Codiersystemen verschlüsselt. So wird z.B. bei der Abrechnung nach §301 und §295 SGB V die Codierung von Diagnosen mittels ICD-10-GM gesetzlich vorgeschrieben. Weitere Codiersysteme sind z.B. die Alpha-ID oder SNOMED CT. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein. DefinitionIm Bereich der administrativen und statistischen Auswertung wird die Diagnose mit Hilfe von Codiersystemen verschlüsselt. So wird z.B. bei der Abrechnung nach §301 und §295 SGB V die Codierung von Diagnosen mittels ICD-10-GM gesetzlich vorgeschrieben. Weitere Codiersysteme sind z.B. die Alpha-ID oder SNOMED CT. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein.
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.ICD10GMDiagnoseKodiert.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ICD10GMDiagnoseKodiert.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ICD10GMDiagnoseKodiert.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Diagnosecode | 1..1 | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Diagnosecode Diagnosecode ICD-10-GM DefinitionCode ohne Zusatzkennzeichen Note that FHIR strings SHALL NOT exceed 1MB in size
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Mehrfachkodierungskennzeichen | 0..1 | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Mehrfachkodierungskennzeichen Mehrfachkodierungskennzeichen DefinitionMehrfachkodierungskennzeichen Kreuz-Stern-System und Ausrufezeichen ("*", "†", "!"). Note that FHIR strings SHALL NOT exceed 1MB in size
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Diagnosesicherheit | 0..1 | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit Zusatzkennzeichen für die Diagnosensicherhe DefinitionDie Diagnosensicherheit, d.h. wie sicher die Diagnose im Einzelfall zu werten ist, kann unterschiedlich angegeben werden. Für Abrechnungszwecke in der ambulanten Versorgung muss obligatorisch ein Zusatzkennzeichen für die Diagnosensicherheit (A, G, V oder Z) angegeben werden, d. h. die Angabe ist obligatorisch. In der stationären Versorgung sind diese Zusatzkennzeichen für die Angabe der Diagnosensicherheit für Abrechnungszwecke dagegen nicht zulässig. Note that FHIR strings SHALL NOT exceed 1MB in size
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Seitenlokalisation | 0..1 | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation Zusatzkennzeichen Seite einer Erkrankung DefinitionZusatzkennzeichen der ICD-10 für die Seitigkeit einer Diagnose (R, L, B) Note that FHIR strings SHALL NOT exceed 1MB in size
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ALPHAIDKodiert | 0..1 | BackboneElement | Element idDiagnose.ALPHAIDKodiert Kodierung einer Diagnose mit Alpha-ID DefinitionKodierung einer Diagnose mit Alpha-ID
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.ALPHAIDKodiert.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ALPHAIDKodiert.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ALPHAIDKodiert.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Diagnosecode | 1..1 | code | Element idDiagnose.ALPHAIDKodiert.Diagnosecode Alpha-ID-Code DefinitionAlpha-ID-Code Note that FHIR strings SHALL NOT exceed 1MB in size
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ORPHANETDiagnoseKodiert | 0..1 | BackboneElement | Element idDiagnose.ORPHANETDiagnoseKodiert Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. DefinitionFür die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich.
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.ORPHANETDiagnoseKodiert.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ORPHANETDiagnoseKodiert.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.ORPHANETDiagnoseKodiert.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Diagnosecode | 1..1 | code | Element idDiagnose.ORPHANETDiagnoseKodiert.Diagnosecode Orpha-Kennnummer DefinitionOrpha-Kennnummer Note that FHIR strings SHALL NOT exceed 1MB in size
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SNOMEDDiagnoseKodiert | 0..1 | BackboneElement | Element idDiagnose.SNOMEDDiagnoseKodiert Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT DefinitionErmöglicht die Kodierung einer Diagnose mit SNOMED-CT
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.SNOMEDDiagnoseKodiert.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.SNOMEDDiagnoseKodiert.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.SNOMEDDiagnoseKodiert.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Diagnosecode | 1..1 | code | Element idDiagnose.SNOMEDDiagnoseKodiert.Diagnosecode SNOMED-CT Code DefinitionSNOMED-CT Code Note that FHIR strings SHALL NOT exceed 1MB in size
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WeitereKodiersysteme | 0..* | BackboneElement | Element idDiagnose.WeitereKodiersysteme Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich. DefinitionBei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich.
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.WeitereKodiersysteme.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.WeitereKodiersysteme.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.WeitereKodiersysteme.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Diagnosecode | 1..1 | code | Element idDiagnose.WeitereKodiersysteme.Diagnosecode Code aus weiterem Kodiersystem DefinitionAngabe des Codes aus weiterem Kodiersystem Note that FHIR strings SHALL NOT exceed 1MB in size
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Koerperstelle | 0..* | code | Element idDiagnose.Koerperstelle Körperstelle DefinitionÜber die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (Topografische Informatiomn) Note that FHIR strings SHALL NOT exceed 1MB in size
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Freitextbeschreibung | 0..1 | string | Element idDiagnose.Freitextbeschreibung Diagnose im Klartext DefinitionDiagnose im Klartext. Im Bereich der medizinischen Dokumentation sollte die Textbeschreibung obligatorisch sein. Bei der sekundären Übernahme einer kodierten Diagonse aus der Primärdokumentation kann eine Freitextbeschreibung fehlen. Note that FHIR strings SHALL NOT exceed 1MB in size
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Diagnoseerlaeuterung | 0..* | string | Element idDiagnose.Diagnoseerlaeuterung Diagnoseerläuterung DefinitionDamit soll dem Arzt die Möglichkeit gegeben werden, umfangreichere Angaben zusätzlich zu einer Diagnose abzufassen. Note that FHIR strings SHALL NOT exceed 1MB in size
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KlinischerStatus | 0..1 | code | Element idDiagnose.KlinischerStatus Klinischer Status Definitionaktiv, Rezidiv, Rückfall, inaktiv, Remission, geheilt Note that FHIR strings SHALL NOT exceed 1MB in size
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KlinischRelevanterZeitraum | 0..1 | BackboneElement | Element idDiagnose.KlinischRelevanterZeitraum Klinisch relevanter Zeitraum DefinitionHier kann der Klinisch Relevante Zeitraum beziehungsweise die Lebensphase einer Erkrankung angegeben werden. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein.
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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Zeitraum | 0..1 | BackboneElement | Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum klinisch relevanter Zeitraum DefinitionDer Zeitraum wird durch zwei Datumsangaben beschrieben, das heißt, von wann bis wann ein Patient an der diagnostizierten Krankheit litt. Über den Zeitraum kann auch ausgedrückt werden, seit wann ein Patient an einer Krankheit leidet, indem nur das Startdatum des Zeitraums angegeben wird. Das Startdatum des Zeitraums kann abweichen von dem Diagnosedatum. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein.
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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von | 0..1 | dateTime | Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.von Startdatum DefinitionStartdatum
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bis | 0..1 | dateTime | Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.bis Enddatum DefinitionEnddatum
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Lebensphase | 0..* | BackboneElement | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase Lebensphase DefinitionLebensphase, in der die Erkrankung aufgetreten ist
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id | 0..1 | string | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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von | 0..1 | code | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.von In welcher Lebensphase die Krankheit began DefinitionIn welcher Lebensphase die Krankheit began Note that FHIR strings SHALL NOT exceed 1MB in size
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bis | 0..1 | code | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.bis In welcher Lebensphase die Krankheit endete DefinitionIn welcher Lebensphase die Krankheit endete Note that FHIR strings SHALL NOT exceed 1MB in size
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Feststellungsdatum | 0..1 | date | Element idDiagnose.Feststellungsdatum Feststellungsdatum / Diagnosedatum DefinitionDas Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt festgestellt wurde. Dies wird im Folgenden mit Diagnosedatum bezeichnet.
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Dokumentationsdatum | 1..1 | date | Element idDiagnose.Dokumentationsdatum Dokumentationsdatum DefinitionDas Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt dokumentiert wurde. Hinweis: Wenn zwischen Feststellung der Diagnose und Dokumentationsdatum nicht unterschieden werden muss, ist das Datum der Feststellung der Diagnose (Diagnosedatum) anzugeben.
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It should be noted that the Logical Model is only intended to map the data elements and their description. The used data types and cardinalities shall not be regarded as obligatory. This is ultimately determined by the FHIR profiles. For each element within the Logical Model there is a 1:1 mapping to an element of a concrete FHIR resource.
Logical data set | Description |
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Diagnose | The basic module Diagnosis contains diagnoses which serve as treatment justifications and billing-based classification features, e.g. as primary diagnoses, secondary diagnoses, quarterly diagnoses etc. |
Diagnose.ICD10GMDiagnoseKodiert | In the field of administrative and statistical evaluation, the diagnosis is encoded using coding systems. The coding of diagnoses using ICD-10 GM, for example, is prescribed by law for billing according to §301 and §295 SGB V. |
Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode | Primary code with secondary codes, if applicable, code system and catalog text |
Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode | Etiology (cause), e.g., which pathogen. The code for the etiology of a disease can be marked with a cross (†) within the ICD coding. |
Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode | Additional note to the etiology code ICD-10: Manifestations. The code for the organ manifestation of a disease is marked with an asterisk (*) in the ICD coding. |
Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode | These additional codes allow a more detailed description of a disease/severity level. |
Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit | The reliability of the diagnosis, i.e. how reliable the diagnosis is in individual cases, can be specified in different ways. For billing purposes in outpatient care, an additional indicator for the certainty of diagnosis (A, G, V or Z) has to be specified, i.e. the specification is mandatory. In inpatient care, however, these additional indicators for specifying the reliability of the diagnosis are not permitted for billing purposes. |
Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation | For the specification of diagnosis information ( ICD-10), the additional labels for laterality (R, L or B) may be specified. The specification is optional; this applies to inpatient and outpatient care. |
Diagnose.ALPHAIDDiagnoseKodiert | Coding of a diagnosis using different code systems should be possible. In this case by using Alpha-ID |
Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode | Alpha-ID, code system and catalog text |
Diagnose.ORPHANETDiagnoseKodiert | Coding of a diagnosis using different code systems should be possible. The ORPHAcodes are required for the coding of rare diseases. |
Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode | OROHAcode, code system and disease name |
Diagnose.SNOMEDDiagnoseKodiert | It should be possible to encode a diagnosis using different code systems. In this case by using SNOMED CT |
Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode | SNOMED-CT code, code system and preferred name |
Diagnose.WeitereKodiersysteme | If required, the addition of further classifications and terminologies is possible. |
Diagnose.WeitereKodiersysteme.VollständigerDiagnosecode | Specification of the code, code system and catalog text |
Diagnose.Körperstelle | The body site can be used to indicate in which area of the body a disease was diagnosed (topographical information). |
Diagnose.Freitextbeschreibung | Diagnosis in plain text. In the area of medical documentation, the text description should be mandatory. |
Diagnose.Diagnoseerläuterung | This allows the physician to provide more detailed information about a diagnosis in the form of free text. |
Diagnose.Dokumentationsdatum | This date is the date on which a disease was documented, e.g. by a physician. Note: If it is not necessary to distinguish between the determination of the diagnosis and the documentation date, the date on which the diagnosis was determined (diagnosis date) has to be entered. |
Diagnose.KlinischerStatus | Specification of the clinical status |
Diagnose.KlinischRelevanterZeitraum | The clinically relevant period or the life phase of a disease can be specified here. Date information on diagnoses may be available in varying degrees of precision. |
Diagnose.KlinischRelevanterZeitraum.Zeitraum | The period is described by two dates, which is from when until when a patient suffered from the diagnosed disease. Through the period it is also possible to express since when a patient has been suffering from a disease by specifying only the start date of the period. The starting date of the period may differ from the diagnosis date. |
Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am | Start date |
Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis | End date |
Diagnose.KlinischRelevanterZeitraum.Lebensphase | Specification of the life phase in which a disease manifests itself |
Diagnose.KlinischRelevanterZeitraum.Lebensphase.von | Start date |
Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis | End date |
Diagnose.Feststellungsdatum | This date is the date on which a disease was diagnosed, e.g. by a doctor. |
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