MII IG Prozedur v2025

Datensätze inkl. Beschreibungen

Die offizielle und abgenommene Version des Informationsmodells für das Modul PROZEDUR ist nachfolgend als FHIR Logical Model abgebildet:

MII_LM_Prozedur (Prozedur)			Element	Element id Prozedur Short description Das Basismodul Prozeduren umfasst die Beschreibung diagnostischer oder therapeutischer Maßnahmen, die als Leistungskomplexe auch für die Abrechnung dokumentiert und kodiert werden, z.B. Operationen. Definition Logische Repräsentation des Basismoduls Prozedur Data type Element Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
OPSProzedurKodiert		0..1	BackboneElement	Element id Prozedur.OPSProzedurKodiert Short description Kodierung der durchgeführten Prozedur mittels OPS. Definition Kodierung der durchgeführten Prozedur mittels OPS. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Procedure.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/ops')
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
VollstaendigerProzedurencode		0..1	Coding	Element id Prozedur.OPSProzedurKodiert.VollstaendigerProzedurencode Short description Vollständiger Prozedurencode Definition Der vollständige Prozedurencode: Tripel aus OPS-Code, Codesystem (inkl. Version!) und Katalogtext. Comments Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Data type Coding Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding FHIR: Procedure.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/ops')
Seitenlokalisation		0..1	Coding	Element id Prozedur.OPSProzedurKodiert.Seitenlokalisation Short description Seitenlokalisation Definition Seitenlokalisation für die durchgeführte Prozedur gemäß BfArM Comments Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Data type Coding Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding FHIR: Procedure.code.coding.where(system='http://fhir.de/CodeSystem/bfarm/ops').extension('http://fhir.de/StructureDefinition/seitenlokalisation').value
SNOMEDProzedurKodiert		0..1	BackboneElement	Element id Prozedur.SNOMEDProzedurKodiert Short description Kodierung der durchgeführten Prozedur mittels SNOMED CT. Definition Kodierung der durchgeführten Prozedur mittels SNOMED CT. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Procedure.code.coding.where(system='http://snomed.info/sct')
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
VollstaendigerProzedurencode		0..1	Coding	Element id Prozedur.SNOMEDProzedurKodiert.VollstaendigerProzedurencode Short description Vollständiger Prozedurencode Definition Der vollständige Prozedurencode: Tripel aus SNOMED-CT-Code, Codesystem (Version optional) und präferierten Namen Comments Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Data type Coding Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding FHIR: Procedure.code.coding.where(system='http://snomed.info/sct')
Koerperstelle		0..*	CodeableConcept	Element id Prozedur.Koerperstelle Short description Körperstelle Definition Körperstelle der Prozedur mittels SNOMED CT inkl. Lateralität (R, L, B) Comments Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Data type CodeableConcept Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD FHIR: Procedure.bodySite
Durchfuehrungsabsicht		0..1	Coding	Element id Prozedur.Durchfuehrungsabsicht Short description Durchführungsabsicht Definition Intention mit der die Prozedur durchgeführt wird. Comments Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Data type Coding Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding FHIR: Procedure.extension('https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht').value
Durchfuehrungsdatum		1..1	dateTime	Element id Prozedur.Durchfuehrungsdatum Short description Durchführungsdatum Definition Das Datum ist der Zeitpunkt, an dem eine Prozedur durchgeführt wurde. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Procedure.performedDateTime
Dokumentationsdatum		0..1	dateTime	Element id Prozedur.Dokumentationsdatum Short description Dokumentationsdatum Definition Das Datum ist der Zeitpunkt, an dem eine Prozedur dokumentiert wurde. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Procedure.extension('http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum').value
Freitextbeschreibung		0..1	string	Element id Prozedur.Freitextbeschreibung Short description Freitextbeschreibung Definition Freitextbeschreibung der durchgeführten Prozedur Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a FHIR: Procedure.code.text

Es ist zu beachten, dass das Logical Model rein auf die Abbildung der Datenelemente und deren Beschreibung abzielt. Verwendete Datentypen und Kardinalitäten sind nicht als verpflichtend anzusehen. Dies wird abschließend durch die FHIR-Profile festgelegt. Für jedes Element innerhalb des Logical Models existiert ein Mapping auf ein Element einer konkreten FHIR Ressource.

Logischer_Datensatz	Beschreibung
Prozedur	Das Basismodul Prozeduren umfasst die Beschreibung diagnostischer oder therapeutischer Maßnahmen, die als Leistungskomplexe auch für die Abrechnung dokumentiert und kodiert werden, z.B. Operationen.
Prozedur.OPSProzedurKodiert	Kodierung der durchgeführten Prozedur mittels OPS.
Prozedur.OPSProzedurKodiert.VollstaendigerProzedurencode	Vollständiger Prozedurencode
Prozedur.OPSProzedurKodiert.Seitenlokalisation	Seitenlokalisation
Prozedur.SNOMEDProzedurKodiert	Kodierung der durchgeführten Prozedur mittels SNOMED CT.
Prozedur.SNOMEDProzedurKodiert.VollstaendigerProzedurencode	Vollständiger Prozedurencode
Prozedur.Koerperstelle	Körperstelle
Prozedur.Durchfuehrungsabsicht	Durchführungsabsicht
Prozedur.Durchfuehrungsdatum	Durchführungsdatum
Prozedur.Dokumentationsdatum	Dokumentationsdatum
Prozedur.Freitextbeschreibung	Freitextbeschreibung