Die offizielle und abgenommene Version des Informationsmodels für das Modul DIAGNOSE findet sich auf ART-DECOR. Zur Vereinheitlichung der Repräsentation wurde das Informationsmodell zusätzlich als FHIR Logical Model abgebildet:
LogicalModelDiagnose (Diagnose) | Element | Element idDiagnose Das Basismodul Diagnosen enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc. DefinitionBase definition for all elements in a resource.
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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..* | 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", SNOMED CT und ID MACS. Die Kodierung einer Diagnose mittels verschiedener Codesysteme sollte möglich sein. DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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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VollstaendigerDiagnosekode | 0..* | code | Element idDiagnose.ICD10GMDiagnoseKodiert.VollstaendigerDiagnosekode Primärcode mit ggf. Sekundärcodes, Codesystem und Katalogtext DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Aetiologiekode | 0..* | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Aetiologiekode Ätiologie (Auslöser), z. B. welcher Erreger. Der Code für die Ätiologie einer Erkrankung wird in der ICD-Codierung mit einem Kreuz (†) gekennzeichnet DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Manifestationskode | 0..* | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Manifestationskode Zusatzangabe zum Ätiologiecode ICD-10: Organmanifestationen. Der Code für die Organmanifestation einer Erkrankung wird in der ICD-Codierung mit einem Stern (*) gekennzeichnet DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Ausrufezeichenkode | 0..* | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode Diese Zusatzcodes dienen zur näheren Beschreibung einer Krankeit/ Abgrenzung des Schweregrades DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Diagnosesicherheit | 0..* | code | Element idDiagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit Primitive Type code 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..* | string | Element idDiagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation Zusatzkennzeichen der ICD-10 für die Seitigkeit einer Diagnose (R, L, B) DefinitionA sequence of Unicode characters Note that FHIR strings SHALL NOT exceed 1MB in size
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ALPHAIDKodiert | 0..* | BackboneElement | Element idDiagnose.ALPHAIDKodiert Kodierung einer Diagnose mit Alpha-ID DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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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VollstaendigerDiagnosekode | 0..* | code | Element idDiagnose.ALPHAIDKodiert.VollstaendigerDiagnosekode AlphaID, Codesystem und Katalogtext DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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ORPHANETDiagnoseKodiert | 0..* | BackboneElement | Element idDiagnose.ORPHANETDiagnoseKodiert Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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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VollstaendigerDiagnosekode | 0..* | code | Element idDiagnose.ORPHANETDiagnoseKodiert.VollstaendigerDiagnosekode Orpha-Kennnummer, Codesystem und Krankheitsname DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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SNOMEDDiagnoseKodiert | 0..* | BackboneElement | Element idDiagnose.SNOMEDDiagnoseKodiert Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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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VollstaendigerDiagnosekode | 0..* | code | Element idDiagnose.SNOMEDDiagnoseKodiert.VollstaendigerDiagnosekode SNOMED-CT Kode, Codesystem und präferierter Name DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents 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. DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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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VollstaendigerDiagnosekode | 0..* | code | Element idDiagnose.WeitereKodiersysteme.VollstaendigerDiagnosekode Angabe des Kodes, Codesystems und des Katalogtextes DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Koerperstelle | 0..* | code | Element idDiagnose.Koerperstelle Über die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (Topografische Informatiomn) DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Freitextbeschreibung | 0..* | string | Element idDiagnose.Freitextbeschreibung Diagnose 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. DefinitionA sequence of Unicode characters Note that FHIR strings SHALL NOT exceed 1MB in size
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Diagnoseerlaeuterung | 0..* | string | Element idDiagnose.Diagnoseerlaeuterung Damit soll dem Arzt die Möglichkeit gegeben werden, umfangreichere Angaben zusätzlich zu einer Diagnose abzufassen. DefinitionA sequence of Unicode characters Note that FHIR strings SHALL NOT exceed 1MB in size
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KlinischerStatus | 0..* | code | Element idDiagnose.KlinischerStatus Status einer Diagnose: active, inactive, ... DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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KlinischRelevanterZeitraum | 0..* | BackboneElement | Element idDiagnose.KlinischRelevanterZeitraum Hier kann der Klinisch Relevante Zeitraum beziehungsweise die Lebensphase einer Erkrankung angegeben werden. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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..* | 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-am | 0..* | dateTime | Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.von-am Startdatum DefinitionA date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.
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bis | 0..* | dateTime | Element idDiagnose.KlinischRelevanterZeitraum.Zeitraum.bis Enddatum DefinitionA date, date-time or partial date (e.g. just year or year + month). If hours and minutes are specified, a time zone SHALL be populated. The format is a union of the schema types gYear, gYearMonth, date and dateTime. Seconds must be provided due to schema type constraints but may be zero-filled and may be ignored. Dates SHALL be valid dates.
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Lebensphase | 0..* | BackboneElement | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase Lebensphase, in der die Erkrankung aufgetreten ist DefinitionBase definition for all elements that are defined inside a resource - but not those in a data type.
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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..* | code | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.von In welcher Lebensphase die Krankheit began DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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bis | 0..* | code | Element idDiagnose.KlinischRelevanterZeitraum.Lebensphase.bis In welcher Lebensphase die Krankheit endete DefinitionA string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Note that FHIR strings SHALL NOT exceed 1MB in size
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Feststellungsdatum | 0..* | date | Element idDiagnose.Feststellungsdatum Das Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt festgestellt wurde. Dies wird im Folgenden mit Diagnosedatum bezeichnet. DefinitionA date or partial date (e.g. just year or year + month). There is no time zone. The format is a union of the schema types gYear, gYearMonth and date. Dates SHALL be valid dates.
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Dokumentationsdatum | 0..* | date | Element idDiagnose.Dokumentationsdatum Das 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. DefinitionA date or partial date (e.g. just year or year + month). There is no time zone. The format is a union of the schema types gYear, gYearMonth and date. Dates SHALL be valid dates.
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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 1:1 Mapping auf ein Element einer konkreten FHIR Ressource
Logischer Datensatz | Beschreibung |
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Diagnose | Das Basismodul Diagnose enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc. |
Diagnose.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. |
Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode | Primärcode mit ggf. Sekundärcodes, Codesystem und Katalogtext |
Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode | Ätiologie (Auslöser), z. B. welcher Erreger. Der Code für die Ätiologie einer Erkrankung kann in der ICD-Codierung mit einem Kreuz (†) gekennzeichnet werden. |
Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode | Zusatzangabe zum Ätiologiecode ICD-10: Manifestationen. Der Code für die Organmanifestation einer Erkrankung wird in der ICD-Codierung mit einem Stern (*) gekennzeichnet. |
Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode | Diese Zusatzcodes dienen zur näheren Beschreibung einer Krankheit/Abgrenzung des Schweregrades. |
Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit | Die 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. |
Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation | Zur Spezifizierung von Diagnoseangaben ( ICD-10) dürfen die Zusatzkennzeichen für die Seitigkeit (R, L oder B) angegeben werden, d.h. die Angabe ist freiwillig; dies gilt für die stationäre und die ambulante Versorgung. |
Diagnose.ALPHAIDDiagnoseKodiert | Die Kodierung einer Diagnose mittels verschiedener Kodesysteme sollte möglich sein. Hier mittels Alpha-ID |
Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode | Alpha-ID, Codesystem und Katalogtext |
Diagnose.ORPHANETDiagnoseKodiert | Die Kodierung einer Diagnose mittels verschiedener Kodesysteme sollte möglich sein. Beispielsweise für die Kodierung von seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. |
Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode | Orpha-Kennnummer, Codesystem und Krankheitsname |
Diagnose.SNOMEDDiagnoseKodiert | Die Kodierung einer Diagnose mittels verschiedener Kodesysteme sollte möglich sein. Hier mittels SNOMED CT |
Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode | SNOMED-CT Kode, Codesystem und PräferierterName |
Diagnose.WeitereKodiersysteme | Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich. |
Diagnose.WeitereKodiersysteme.VollständigerDiagnosecode | Angabe des Codes, Codesystems und des Katalogtexts |
Diagnose.Körperstelle | Über die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (Topographische Information). |
Diagnose.Freitextbeschreibung | Diagnose im Klartext. Im Bereich der medizinischen Dokumentation sollte die Textbeschreibung obligatorisch sein. |
Diagnose.Diagnoseerläuterung | Damit soll dem Arzt die Möglichkeit gegeben werden evt. nähere Angaben zu einer Diagnose in Form von Freitext zu machen. |
Diagnose.Dokumentationsdatum | Das 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. |
Diagnose.KlinischerStatus | Angabe des Klinischen Status |
Diagnose.KlinischRelevanterZeitraum | Hier kann der Klinisch Relevante Zeitraum beziehungsweise die Lebensphase einer Erkrankung angegeben werden. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. |
Diagnose.KlinischRelevanterZeitraum.Zeitraum | Der 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. |
Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am | Startdatum |
Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis | Enddatum |
Diagnose.KlinischRelevanterZeitraum.Lebensphase | Angabe der Lebensphase einer Erkrankung |
Diagnose.KlinischRelevanterZeitraum.Lebensphase.von | Startdatum |
Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis | Enddatum |
Diagnose.Feststellungsdatum | Das Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt festgestellt wurde. |
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