MII_IG_Diagnose_EN

Data sets including description

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:

LogicalModelDiagnose (Diagnose)			Element	Element id Diagnose Short description Das Basismodul Diagnosen enthält Diagnosen als Behandlungsbegründungen und abrechnungsbasiertes Gliederungsmerkmal, z.B. als Hauptdiagnose, Nebendiagnose, Quartalsdiagnose etc. Definition Base definition for all elements in a resource. 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 Diagnose.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 Diagnose.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
ICD10GMDiagnoseKodiert		0..*	BackboneElement	Element id Diagnose.ICD10GMDiagnoseKodiert Short description 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. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ICD10GMDiagnoseKodiert.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 Diagnose.ICD10GMDiagnoseKodiert.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 Diagnose.ICD10GMDiagnoseKodiert.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
VollstaendigerDiagnosekode		0..*	code	Element id Diagnose.ICD10GMDiagnoseKodiert.VollstaendigerDiagnosekode Short description Primärcode mit ggf. Sekundärcodes, Codesystem und Katalogtext Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Aetiologiekode		0..*	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Aetiologiekode Short description Ätiologie (Auslöser), z. B. welcher Erreger. Der Code für die Ätiologie einer Erkrankung wird in der ICD-Codierung mit einem Kreuz (†) gekennzeichnet Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Manifestationskode		0..*	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Manifestationskode Short description Zusatzangabe zum Ätiologiecode ICD-10: Organmanifestationen. Der Code für die Organmanifestation einer Erkrankung wird in der ICD-Codierung mit einem Stern () gekennzeichnet Definition* A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Ausrufezeichenkode		0..*	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Ausrufezeichenkode Short description Diese Zusatzcodes dienen zur näheren Beschreibung einer Krankeit/ Abgrenzung des Schweregrades Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Diagnosesicherheit		0..*	code	Element id Diagnose.ICD10GMDiagnoseKodiert.Diagnosesicherheit Short description Primitive Type code Definition 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. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Seitenlokalisation		0..*	string	Element id Diagnose.ICD10GMDiagnoseKodiert.Seitenlokalisation Short description Zusatzkennzeichen der ICD-10 für die Seitigkeit einer Diagnose (R, L, B) Definition A sequence of Unicode characters 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
ALPHAIDKodiert		0..*	BackboneElement	Element id Diagnose.ALPHAIDKodiert Short description Kodierung einer Diagnose mit Alpha-ID Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ALPHAIDKodiert.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 Diagnose.ALPHAIDKodiert.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 Diagnose.ALPHAIDKodiert.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
VollstaendigerDiagnosekode		0..*	code	Element id Diagnose.ALPHAIDKodiert.VollstaendigerDiagnosekode Short description AlphaID, Codesystem und Katalogtext Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
ORPHANETDiagnoseKodiert		0..*	BackboneElement	Element id Diagnose.ORPHANETDiagnoseKodiert Short description Für die Kodierung von Seltenen Krankheiten ist die Orpha-Kennnummer erforderlich. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.ORPHANETDiagnoseKodiert.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 Diagnose.ORPHANETDiagnoseKodiert.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 Diagnose.ORPHANETDiagnoseKodiert.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
VollstaendigerDiagnosekode		0..*	code	Element id Diagnose.ORPHANETDiagnoseKodiert.VollstaendigerDiagnosekode Short description Orpha-Kennnummer, Codesystem und Krankheitsname Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
SNOMEDDiagnoseKodiert		0..*	BackboneElement	Element id Diagnose.SNOMEDDiagnoseKodiert Short description Ermöglicht die Kodierung einer Diagnose mit SNOMED-CT Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.SNOMEDDiagnoseKodiert.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 Diagnose.SNOMEDDiagnoseKodiert.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 Diagnose.SNOMEDDiagnoseKodiert.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
VollstaendigerDiagnosekode		0..*	code	Element id Diagnose.SNOMEDDiagnoseKodiert.VollstaendigerDiagnosekode Short description SNOMED-CT Kode, Codesystem und präferierter Name Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
WeitereKodiersysteme		0..*	BackboneElement	Element id Diagnose.WeitereKodiersysteme Short description Bei Bedarf ist die Aufnahme weiterer Klassifikationen und Terminologien möglich. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.WeitereKodiersysteme.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 Diagnose.WeitereKodiersysteme.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 Diagnose.WeitereKodiersysteme.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
VollstaendigerDiagnosekode		0..*	code	Element id Diagnose.WeitereKodiersysteme.VollstaendigerDiagnosekode Short description Angabe des Kodes, Codesystems und des Katalogtextes Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Koerperstelle		0..*	code	Element id Diagnose.Koerperstelle Short description Über die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (Topografische Informatiomn) Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Freitextbeschreibung		0..*	string	Element id Diagnose.Freitextbeschreibung Short description 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. Definition A sequence of Unicode characters 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
Diagnoseerlaeuterung		0..*	string	Element id Diagnose.Diagnoseerlaeuterung Short description Damit soll dem Arzt die Möglichkeit gegeben werden, umfangreichere Angaben zusätzlich zu einer Diagnose abzufassen. Definition A sequence of Unicode characters 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
KlinischerStatus		0..*	code	Element id Diagnose.KlinischerStatus Short description Status einer Diagnose: active, inactive, ... Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
KlinischRelevanterZeitraum		0..*	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum Short description Hier kann der Klinisch Relevante Zeitraum beziehungsweise die Lebensphase einer Erkrankung angegeben werden. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.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 Diagnose.KlinischRelevanterZeitraum.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 Diagnose.KlinischRelevanterZeitraum.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
Zeitraum		0..*	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum Short description klinisch relevanter Zeitraum Definition 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. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.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 Diagnose.KlinischRelevanterZeitraum.Zeitraum.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 Diagnose.KlinischRelevanterZeitraum.Zeitraum.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
von-am		0..*	dateTime	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.von-am Short description Startdatum Definition A 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. 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
bis		0..*	dateTime	Element id Diagnose.KlinischRelevanterZeitraum.Zeitraum.bis Short description Enddatum Definition A 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. 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
Lebensphase		0..*	BackboneElement	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase Short description Lebensphase, in der die Erkrankung aufgetreten ist Definition Base definition for all elements that are defined inside a resource - but not those in a data type. 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
id		0..1	string	There are no (further) constraints on this element Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.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 Diagnose.KlinischRelevanterZeitraum.Lebensphase.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 Diagnose.KlinischRelevanterZeitraum.Lebensphase.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
von		0..*	code	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.von Short description In welcher Lebensphase die Krankheit began Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
bis		0..*	code	Element id Diagnose.KlinischRelevanterZeitraum.Lebensphase.bis Short description In welcher Lebensphase die Krankheit endete Definition A 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 Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Feststellungsdatum		0..*	date	Element id Diagnose.Feststellungsdatum Short description Das Datum ist der Zeitpunkt, an dem eine Krankheit z. B. durch einen Arzt festgestellt wurde. Dies wird im Folgenden mit Diagnosedatum bezeichnet. Definition A 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. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
Dokumentationsdatum		0..*	date	Element id Diagnose.Dokumentationsdatum Short description 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. Definition A 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. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a

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
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.