Condition

This profile describes a diagnosis within the Medical Informatics Initiative.

Canonical: https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose

Differential

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
verificationStatusΣ ?! I0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
DiagnosesicherheitS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
AusrufezeichenCodeS I0..*Extension(CodingICD10GM)
ManifestationsCodeS I0..*Extension(CodingICD10GM)
PrimaercodeS I0..*Extension(CodingICD10GM)
systemS Σ1..1uriPattern
versionS Σ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation



FHIR element Explanation
Condition.id Must-support, but optional
Condtion.meta Must-support, but optional
Condtion.clinicalStatus No restrictions, complete diagnostic workflow is supported. The element is optional because it is not recorded routinely. In addition, the status is not usually captured at discharge.
Condtion.code Min. 1 coded diagnosis has to be included. System can be selected from Alpha-ID, SNOMED CT, Orpahanet and ICD-10 GM.
Condtion.code.coding:icd10-gm.extension Within the extensions "AusrufezeichenCode", "ManifestationsCode" and "Primaercode", the respective code components should be coded without respective special characters (e.g. "!", "+" or "*").
Condtion.bodySite In case this optional element is used, the body site has to be coded at least with one SNOMED-CT code. It is not necessary to specify the laterality here, this should be specified per Condition.code.coding:icd10-gm.extenison:site localization. This field is used to document additional information (beyond the code) about the manifestation.
Condtion.subject The reference to the module person is always given.
Condition.encounter It should be noted that in most cases this field should not be used to link the case and the diagnosis. This element is used to link the diagnosis to the encounter / contact in which the diagnosis is determined (always a contact with a concrete care center!). In general, the linking should be done via Encounter.diagnosis.
Condtion.onset[x] Following the IPS, it can be coded as Period or dateTime. Life phases can additionally be specified if exact times are unknown.
Condtion.recordedDate Serves for the chronological classification of the diagnosis (instead of the queries on the initial 'Abteilungsfall' of the determination of the diagnosis).
Condtion.note Additional explanation of the diagnosis.

FHIR element Explanation
Encounter.period.start / Diagnose.encounter It should be noted that the mapping of the logical data element "Feststellungsdatum" is not performed on the Condition resource but on the Encounter resource. Thus, the linking of the diagnosis SHOULD always be done to a facility contact (See Case module).

FHIR Element Logical dataset
Condition.code:icd-10gm Diagnose.ICD10GMDiagnoseKodiert
Condition.code:icd-10gm.coding.code Diagnose.ICD10GMDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:icd-10gm.coding:extension:Primaercode Diagnose.ICD10GMDiagnoseKodiert.Ätiologiekode
Condition.code:icd-10gm.coding:extension:ManifestationsCode Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode
Condition.code:icd-10gm.coding:extension:AusrufezeichenCode Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode
Condition.code:icd-10gm.coding:extension:Diagnosesicherheit Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit
Condition.code:icd-10gm.coding:extension:Seitenlokalisation Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation
Condition.code:alpha-id Diagnose.ALPHAIDDiagnoseKodiert
Condition.code:alpha-id (coding.system, coding.value) Diagnose.ALPHAIDDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:orphanet Diagnose.ORPHANETDiagnoseKodiert
Condition.code:orphanet (coding.system, coding.value) Diagnose.ORPHANETDiagnoseKodiert.VollständigerDiagnosecode
Condition.code:sct Diagnose.SNOMEDDiagnoseKodiert
Condition.code:sct (coding.system, coding.value) Diagnose.SNOMEDDiagnoseKodiert.VollständigerDiagnosecode
Condition.code Diagnose.WeitereKodiersysteme
Condition.code (coding.system, coding.value) Diagnose.WeitereKodesysteme.VollständigerDiagnosecode
Condition.bodySite Diagnose.Körperstelle
Condition.code.text Diagnose.Freitextbeschreibung
Condition.note Diagnose.Diagnoseerläuterung
Condition.recordedDate Diagnose.Dokumentationsdatum
Condition.clinicalStatus Diagnose.KlinscherStatus
Condition.onset[x] Diagnose.KlinischRelevanterZeitraum
Condition.onsetPeriod Diagnose.KlinischRelevanterZeitraum.Zeitraum
Condition.onsetPeriod.start Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am
Condition.onsetPeriod.end Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis
n.A. Diagnose.KlinischRelevanterZeitraum.Lebensphase
Condition.onsetPeriod.start.extension:lebensphase-start Diagnose.KlinischRelevanterZeitraum.Lebensphase.von
Condition.onsetPeriod.end.extension:lebensphase-ende Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis

FHIR element Logical dataset
Encounter.period.start Diagnose.Feststellungsdatum

The invariants of the German Basic Profiles for the data type Profile 'Coding Profile for ICD-10-GM' and the Extension for Diagnostic Certainty must be taken into account.


Snapshot

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
identifierΣ0..*Identifier
clinicalStatusS Σ ?! I0..1CodeableConceptBinding
verificationStatusΣ ?! I0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
id0..1string
extensionI0..*Extension
id0..1string
DiagnosesicherheitS I0..1Extension(Coding)
SeitenlokalisationS I0..1Extension(Coding)
AusrufezeichenCodeS I0..*Extension(CodingICD10GM)
ManifestationsCodeS I0..*Extension(CodingICD10GM)
PrimaercodeS I0..*Extension(CodingICD10GM)
systemS Σ1..1uriPattern
versionS Σ1..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group)
encounterΣ I0..1Reference(Encounter)
id0..1string
extensionI0..*Extension
id0..1string
lebensphase-vonS I0..1Extension(CodeableConcept)
value0..1System.DateTime
id0..1string
lebensphase-bisS I0..1Extension(CodeableConcept)
value0..1System.DateTime
onsetDateTimeS Σ0..1dateTime
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateS Σ1..1dateTime
recorderΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
asserterΣ I0..1Reference(Practitioner | PractitionerRole | Patient | RelatedPerson)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
summaryI0..1CodeableConcept
assessmentI0..*Reference(ClinicalImpression | DiagnosticReport | Observation)
type0..1CodeableConcept
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
codeΣ I0..*CodeableConcept
detailΣ I0..*Reference(Resource)
noteS0..*Annotation


Examples

ICD-10-GM & SNOMED CT:

{
    "resourceType": "Condition",
    "id": "ExampleCondition",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2020",
                "code": "S50.0",
                "display": "Prellung des Ellenbogens"
            },
            {
                "system": "http://snomed.info/sct",
                "code": "91613004",
                "display": "Contusion of elbow (disorder)"
            }
        ],
        "text": "Prellung des linken Ellenbogens"
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "onsetPeriod": {
        "start": "2020-02-26T12:00:00+01:00",
        "end": "2020-03-05T13:00:00+01:00"
    },
    "recordedDate": "2020-02-26T12:00:00+01:00"
}

ICD-10-GM diagnosis with 'Kreuz-Stern-System' and 'Zusatzkennzeichen':

{
    "resourceType": "Condition",
    "id": "ExampleConditionDuplicate2",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-primaercode",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2020",
                            "code": "A54.4"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2020",
                            "code": "M73.04"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit",
                        "valueCoding": {
                            "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT",
                            "code": "G"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/seitenlokalisation",
                        "valueCoding": {
                            "system": "https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION",
                            "code": "L",
                            "display": "links"
                        }
                    }
                ],
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2020",
                "code": "A54.4† M73.04*",
                "display": "Bursitis gonorrhoica"
            }
        ]
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "onsetPeriod": {
        "start": "2019-09-26T12:45:00+01:00",
        "end": "2020-03-25T13:00:00+01:00"
    },
    "recordedDate": "2020-01-05T12:53:00+01:00"
}

Alpha-ID and Orpha-Kennnummer:

{
    "resourceType": "Condition",
    "id": "ExampleConditionDuplicate3",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "active"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2020",
                "code": "H83.8",
                "display": "Sonstige näher bezeichnete Krankheiten des Innenohres"
            },
            {
                "system": "http://fhir.de/ValueSet/dimdi/alpha-id",
                "code": "I125918"
            },
            {
                "system": "http://www.orpha.net",
                "code": "420402",
                "display": "Bogengangsdehiszenz-Syndrom"
            }
        ]
    },
    "subject": {
        "reference": "Patient/12345"
    },
    "onsetPeriod": {
        "start": "2020-02-13T16:56:00+01:00"
    },
    "recordedDate": "2020-04-26T12:00:00+01:00"
}