MII-Initiative

Medizininformatik Initiative - Modul Pathologie-Befund - ImplementationGuide

MII PR Patho History of Present Illness

Beschreibung

Das Profil MII PR Patho History of Present Illness der Resource List bildet die Beschreibung der Anamnese durch den Einsender ab und ist Teil der "supportingInfo" im Profil MII PR Patho Service Request ab.

Die einzelnen Erkrankungen/Probleme können mithilfe des Profils MII PR Patho Problem List Item dargestellt werden.

NameCanonical
MII_PR_Patho_History_Of_Present_Illnesshttps://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-history-of-present-illness

idΣ0..1string
id0..1string
extensionI0..*Extension
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lastUpdatedΣ0..1instant
sourceΣ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
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identifier0..*Identifier
statusS Σ ?!1..1codeBinding
modeS Σ ?!1..1codeBindingFixed Value
titleΣ0..1string
id0..1string
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extensionI0..*Extension
systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
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subjectS Σ I1..1Reference(Patient | Group | Device | Location)
encounterI0..1Reference(Encounter)
dateΣ0..1dateTime
sourceΣ I0..1Reference(Practitioner | PractitionerRole | Patient | Device)
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note0..*Annotation
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extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
flag0..1CodeableConcept
deleted?! I0..1boolean
date0..1dateTime
itemI1..1Reference(MII_PR_Patho_Problem_List_Item)
emptyReasonI0..1CodeableConceptBinding
idΣ0..1string
id0..1string
extensionI0..*Extension
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securityΣ0..*CodingBinding
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implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
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extensionI0..*Extension
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identifier0..*Identifier
statusS Σ ?!1..1codeBinding
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systemΣ1..1uriPattern
versionΣ0..1string
codeΣ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1Reference(Patient | Group | Device | Location)
encounterI0..1Reference(Encounter)
dateΣ0..1dateTime
sourceΣ I0..1Reference(Practitioner | PractitionerRole | Patient | Device)
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note0..*Annotation
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modifierExtensionΣ ?! I0..*Extension
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itemI1..1Reference(MII_PR_Patho_Problem_List_Item)
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subjectS Σ I1..1Reference(Patient | Group | Device | Location)
encounterI0..1Reference(Encounter)
dateΣ0..1dateTime
sourceΣ I0..1Reference(Practitioner | PractitionerRole | Patient | Device)
orderedBy0..1CodeableConceptBinding
note0..*Annotation
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date0..1dateTime
itemI1..1Reference(MII_PR_Patho_Problem_List_Item)
emptyReasonI0..1CodeableConceptBinding
{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-patho-history-of-present-illness",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-history-of-present-illness",
    "version": "1.0.0",
    "name": "MII_PR_Patho_History_Of_Present_Illness",
    "title": "MII PR Patho History Of Present Illness",
    "status": "active",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "List profile for 'History of Present Illness'",
    "fhirVersion": "4.0.1",
    "mapping":  [
        {
            "identity": "rim",
            "uri": "http://hl7.org/v3",
            "name": "RIM Mapping"
        },
        {
            "identity": "w5",
            "uri": "http://hl7.org/fhir/fivews",
            "name": "FiveWs Pattern Mapping"
        }
    ],
    "kind": "resource",
    "abstract": false,
    "type": "List",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/List",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "List.meta.profile",
                "path": "List.meta.profile",
                "mustSupport": true
            },
            {
                "id": "List.status",
                "path": "List.status",
                "mustSupport": true
            },
            {
                "id": "List.mode",
                "path": "List.mode",
                "fixedCode": "snapshot",
                "mustSupport": true
            },
            {
                "id": "List.code",
                "path": "List.code",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "List.code.coding",
                "path": "List.code.coding",
                "min": 1,
                "patternCoding": {
                    "code": "8684-3",
                    "system": "http://loinc.org"
                },
                "mustSupport": true
            },
            {
                "id": "List.code.coding.system",
                "path": "List.code.coding.system",
                "min": 1
            },
            {
                "id": "List.code.coding.code",
                "path": "List.code.coding.code",
                "min": 1
            },
            {
                "id": "List.subject",
                "path": "List.subject",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "List.entry",
                "path": "List.entry",
                "mustSupport": true
            },
            {
                "id": "List.entry.item",
                "path": "List.entry.item",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-problem-list-item"
                        ]
                    }
                ]
            }
        ]
    }
}

Liste aller Must-Support Datenelemente

FHIR-Element Erklärung
List.status Finale & vorläufige Ergebnisse sind zulässig
List.mode Fixed auf #snapshot (This list was prepared as a snapshot. It should not be assumed to be current.)
List.code Pattern Coding auf LOINC 8684-3 "History of Present illness"
List.subject Referenz auf Patient:in
List.entry Referenz auf MII PR Patho Problem List Item

Referenz zum Logical Model

FHIR-Element Logisches Datenmodell

Beispiele

{
    "resourceType": "List",
    "id": "mii-exa-patho-history-of-present-illness",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-history-of-present-illness"
        ]
    },
    "mode": "snapshot",
    "code": {
        "coding":  [
            {
                "code": "8684-3",
                "system": "http://loinc.org",
                "display": "History of Present illness"
            }
        ]
    },
    "status": "current",
    "subject": {
        "reference": "Patient/12345"
    },
    "entry":  [
        {
            "item": {
                "reference": "Condition/mii-exa-patho-problem-list-item-2"
            }
        }
    ]
}