<status value="draft" /> <publisher value="Medizininformatik Initiative" /> <contact> <telecom> <system value="url" /> <value value="https://www.medizininformatik-initiative.de" /> </telecom> </contact> <description value="Intensive Care Delirium Screening Checklist (ICDSC) for delirium assessment. Evaluates 8 items over a shift (usually 8-12 hours). Each item scores 0 (absent) or 1 (present). Total score ranges from 0-8. A score of 0: no delirium, 1-3: subsyndromal delirium, ≥4: delirium." /> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="Observation" /> <baseDefinition value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score" /> <derivation value="constraint" /> <differential> <element id="Observation.code.coding:sct"> <path value="Observation.code.coding" /> <sliceName value="sct" /> <patternCoding> <system value="http://snomed.info/sct" /> <code value="1351995008" /> <display value="Intensive Care Delirium Screening Checklist score (observable entity)" /> </patternCoding> </element> <element id="Observation.value[x]"> <path value="Observation.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.value[x]:valueInteger"> <path value="Observation.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-score-range" /> <severity value="error" /> <human value="ICDSC total score must be between 0 and 8" /> <expression value="value >= 0 and value <= 8" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.interpretation"> <path value="Observation.interpretation" /> <short value="Delirium status" /> <definition value="No delirium (0), subsyndromal delirium (1-3), delirium (≥4)" /> <binding> <strength value="extensible" /> <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/delirium-interpretation" /> </binding> </element> <element id="Observation.component"> <path value="Observation.component" /> <slicing> <discriminator> <type value="pattern" /> <path value="code" /> </discriminator> <rules value="closed" /> </slicing> <min value="8" /> <max value="8" /> </element> <element id="Observation.component:altered-consciousness"> <path value="Observation.component" /> <sliceName value="altered-consciousness" /> <short value="Altered consciousness" /> <definition value="No response (5 points in GCS), need for vigorous stimulation to obtain any response (1 point), or spontaneously drowsy (RASS -1 to -3) but easy to arouse (1 point)" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:altered-consciousness.code.text"> <path value="Observation.component.code.text" /> <patternString value="Altered level of consciousness" /> </element> <element id="Observation.component:altered-consciousness.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:altered-consciousness.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:inattention"> <path value="Observation.component" /> <sliceName value="inattention" /> <short value="Inattention" /> <definition value="Difficulty following conversation or instructions, easily distracted by external stimuli, difficulty shifting focus" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:inattention.code.text"> <path value="Observation.component.code.text" /> <patternString value="Inattention" /> </element> <element id="Observation.component:inattention.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:inattention.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:disorientation"> <path value="Observation.component" /> <sliceName value="disorientation" /> <short value="Disorientation" /> <definition value="Manifest disorientation to time, place, or person (≥ 1 error)" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:disorientation.code.text"> <path value="Observation.component.code.text" /> <patternString value="Disorientation" /> </element> <element id="Observation.component:disorientation.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:disorientation.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:hallucination-delusion"> <path value="Observation.component" /> <sliceName value="hallucination-delusion" /> <short value="Hallucination, delusion, or psychosis" /> <definition value="Clinical manifestation of hallucination or behavior suggestive of hallucination, gross distortion or misrepresentation of reality" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:hallucination-delusion.code.text"> <path value="Observation.component.code.text" /> <patternString value="Hallucination, delusion, or psychosis" /> </element> <element id="Observation.component:hallucination-delusion.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:hallucination-delusion.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:psychomotor-agitation-retardation"> <path value="Observation.component" /> <sliceName value="psychomotor-agitation-retardation" /> <short value="Psychomotor agitation or retardation" /> <definition value="Hyperactivity requiring sedation or restraints, hypoactivity or clinically noticeable psychomotor slowing" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:psychomotor-agitation-retardation.code.text"> <path value="Observation.component.code.text" /> <patternString value="Psychomotor agitation or retardation" /> </element> <element id="Observation.component:psychomotor-agitation-retardation.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:psychomotor-agitation-retardation.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:inappropriate-speech-mood"> <path value="Observation.component" /> <sliceName value="inappropriate-speech-mood" /> <short value="Inappropriate speech or mood" /> <definition value="Inappropriate, disorganized, or incoherent speech, inappropriate display of emotion" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:inappropriate-speech-mood.code.text"> <path value="Observation.component.code.text" /> <patternString value="Inappropriate speech or mood" /> </element> <element id="Observation.component:inappropriate-speech-mood.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:inappropriate-speech-mood.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:sleep-wake-disturbance"> <path value="Observation.component" /> <sliceName value="sleep-wake-disturbance" /> <short value="Sleep/wake cycle disturbance" /> <definition value="Sleeping less than 4 hours or frequent awakening at night, sleeping most of the day" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:sleep-wake-disturbance.code.text"> <path value="Observation.component.code.text" /> <patternString value="Sleep/wake cycle disturbance" /> </element> <element id="Observation.component:sleep-wake-disturbance.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:sleep-wake-disturbance.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> <element id="Observation.component:symptom-fluctuation"> <path value="Observation.component" /> <sliceName value="symptom-fluctuation" /> <short value="Symptom fluctuation" /> <definition value="Fluctuation of manifestation of any item or symptom over 24 hours" /> <min value="1" /> <max value="1" /> <mustSupport value="true" /> </element> <element id="Observation.component:symptom-fluctuation.code.text"> <path value="Observation.component.code.text" /> <patternString value="Symptom fluctuation" /> </element> <element id="Observation.component:symptom-fluctuation.value[x]"> <path value="Observation.component.value[x]" /> <slicing> <discriminator> <type value="type" /> <path value="$this" /> </discriminator> <ordered value="false" /> <rules value="open" /> </slicing> <min value="1" /> </element> <element id="Observation.component:symptom-fluctuation.value[x]:valueInteger"> <path value="Observation.component.value[x]" /> <sliceName value="valueInteger" /> <min value="1" /> <max value="1" /> <type> <code value="integer" /> </type> <constraint> <key value="icdsc-item-range" /> <severity value="error" /> <human value="ICDSC item score must be 0 or 1" /> <expression value="value = 0 or value = 1" /> <source value="https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-icdsc" /> </constraint> </element> </differential> </StructureDefinition>