Generated Narrative: StructureDefinition ISiKDiagnose Name Flags Card. Type Description & Constraints Condition C 0..* Condition Detailed information about conditions, problems or diagnoses Constraints: isik-con1 #xD; id S 0..1 id serverseitige, interne ID des Datensatzes #xD; meta #xD; versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes #xD; lastUpdated 0..1 instant Zeitpunkt der letzten Änderung #xD; implicitRules 0..0 Verweis auf die Regeln, nach denen die Ressource erstellt wurde #xD; Slices for extension S 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:related S 0..1 Reference(Condition) Verknüpfte Diagnose URL: http://hl7.org/fhir/StructureDefinition/condition-related #xD; clinicalStatus S 0..1 CodeableConcept klinischer Status #xD; verificationStatus S 0..1 CodeableConcept Bestätigungsstatus #xD; category 0..* CodeableConcept problem-list-item | encounter-diagnosis #xD; severity 0..1 CodeableConcept Subjective severity of condition #xD; code SC 1..1 CodeableConcept Diagnose-Code Constraints: icd-text-1 #xD; Slices for coding S 0..* Coding Code defined by a terminology system Slice: Unordered, Open by pattern:$this #xD; coding:ICD-10-GM S 0..1 ISiKICD10GMCoding Code defined by a terminology system Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm #xD; Slices for extension Content/Rules for all slices #xD; extension:Mehrfachcodierungs-Kennzeichen S 0..1 ExtensionMehrfachcodierungKennzeichen Optional Extensions Element #xD; extension:Seitenlokalisation S 0..1 ExtensionSeitenlokalisation Seitenlokalisation #xD; extension:Diagnosesicherheit S 0..1 ExtensionICD10GMDiagnosesicherheit Optional Extensions Element #xD; coding:Alpha-ID S 0..1 CodingAlphaID Code defined by a terminology system Required Pattern: At least the following #xD; system S 1..1 uri Canonische CodeSystem URL für Alpha-ID Fixed Value: http://fhir.de/CodeSystem/bfarm/alpha-id #xD; code S 1..1 code Der Alpha-ID-Code #xD; coding:SNOMED-CT S 0..1 ISiKSnomedCTCoding Code defined by a terminology system Binding: DiagnosesSCT (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; coding:Orphanet S 0..1 Coding Code defined by a terminology system Required Pattern: At least the following #xD; system S 1..1 uri Identity of the terminology system Fixed Value: http://www.orpha.net #xD; code 1..1 code Symbol in syntax defined by the system #xD; bodySite S 0..* CodeableConcept Körperstelle #xD; Slices for extension Content/Rules for all slices #xD; extension:BodyStructureReference 0..1 Reference(BodyStructure) Referenz auf eine BodyStructure-Ressource URL: http://hl7.org/fhir/StructureDefinition/bodySite #xD; Slices for coding S 0..* Coding Code defined by a terminology system Slice: Unordered, Open by pattern:system #xD; coding:snomed-ct S 0..1 ISiKSnomedCTCoding Code defined by a terminology system #xD; subject S 1..1 Reference(Patient | Group) Patientenbezug #xD; reference S 1..1 string Patienten-Link #xD; encounter S 0..1 Reference(Encounter) Aufenthaltsbezug #xD; reference S 1..1 string Encounter-Link #xD; Slices for onset[x] S 0..1 Erkrankungsbeginn Slice: Unordered, Open by type:$this #xD; onsetDateTime dateTime #xD; onsetAge Age #xD; onset[x]:onsetDateTime S 0..1 dateTime Erkrankungsbeginn als Datum #xD; onset[x]:onsetAge S 0..1 Age Erkrankungsbeginn als Alter #xD; Slices for extension Content/Rules for all slices #xD; extension:Lebensphase-Beginn 0..1 CodeableConcept Lebensphase des Erkrankungsbeginns URL: http://fhir.de/StructureDefinition/lebensphase #xD; Slices for abatement[x] S 0..1 Klinische relevanter Zeitraum Ende Slice: Unordered, Open by type:$this #xD; abatementDateTime dateTime #xD; abatementAge Age #xD; abatement[x]:abatementAge S 0..1 Age Klinische relevanter Zeitraum Ende als Alter #xD; Slices for extension Content/Rules for all slices #xD; extension:Lebensphase-Ende 0..1 CodeableConcept Lebensphase des Erkrankungsendes URL: http://fhir.de/StructureDefinition/lebensphase #xD; abatement[x]:abatementDateTime S 0..1 dateTime Klinische relevanter Zeitraum Ende als Datum #xD; recordedDate S 1..1 dateTime Dokumentationsdatum #xD; note S 0..* Annotation Notizen #xD; Documentation for this format
Dieses Profil spezifiziert die Minimalanforderungen für die Bereitstellung von Informationen über die Diagnosen eines Patienten im Rahmen des Bestätigungsverfahrens der gematik. **Motivation** Die Möglichkeit, auf eine Übersicht der Diagnosen eines Patienten zuzugreifen, Patienten anhand ihrer Diagnose zu suchen oder zu prüfen, ob eine konkrete Diagnose bei einem Patienten vorliegt, sind wichtige Funktionen im klinischen Behandlungsablauf. In FHIR werden Diagnosen mit der Condition-Ressource repräsentiert. Da die Diagnosen in klinischen Primärsystemen in der Regel in ICD-10-codierter Form vorliegen, fordert ISiK in erster Linie diese Form des Austausches. Falls eine Diagnose zwar dokumentiert, aber noch nicht codiert wurde (z.B. wenn die Kodierung erst nach der Entlassung erfolgt), ist alternativ eine Repräsentation als Freitext-Diagnose möglich. **Kompatibilität** Für das Profil ISiKDiagnose wird eine Kompatibilität mit folgenden Profilen angestrebt; allerdings kann nicht sichergestellt werden, dass Instanzen, die gegen ISiKDiagnose valide sind, auch valide sind gegen: * das [Profil ProfileConditionDiagnose der Medizininformatik-Initative](https://www.medizininformatik-initiative.de/fhir/core/modul-diagnose/StructureDefinition/Diagnose) * das [Profil KBV_PR_Base_Condition_Diagnosis der KBV](https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Condition_Diagnosis)] Hinweise zu Inkompatibilitäten können über die [Portalseite](https://service.gematik.de/servicedesk/customer/portal/16) gemeldet werden.
Detailed information about conditions, problems or diagnoses
A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.
Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.
Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
exists(f:clinicalStatus) or exists(f:verificationStatus/f:coding/f:code/@value='entered-in-error') or not(exists(category[@value='problem-list-item']))
If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
not(exists(*[starts-with(local-name(.), 'abatement')])) or exists(f:clinicalStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-clinical' and f:code/@value=('resolved', 'remission', 'inactive')])
Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
not(exists(f:verificationStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-ver-status' and f:code/@value='entered-in-error'])) or not(exists(f:clinicalStatus))
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Falls eine kodierte Diagnose vorliegt muss angegeben werden durch welchen Kontakt diese Dokumentation erfolgte.
code.coding.exists() implies encounter.exists()
< 243796009 |Situation with explicit context| : 246090004 |Associated finding| = ( ( < 404684003 |Clinical finding| MINUS ( << 420134006 |Propensity to adverse reactions| OR << 473010000 |Hypersensitivity condition| OR << 79899007 |Drug interaction| OR << 69449002 |Drug action| OR << 441742003 |Evaluation finding| OR << 307824009 |Administrative status| OR << 385356007 |Tumor stage finding|)) OR < 272379006 |Event|)
Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
serverseitige, interne ID des Datensatzes
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
**bedingtes Pflichtfeld/bedingtes MS:** Alle von einem Server bereitgestellten Ressourcen MÜSSEN über eine `id` verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine `id`verfügen.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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.
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Eindeutiger Name der serverseitigen Version des Datensatzes
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Alle von einem Server bereitgestellten Ressourcen SOLLEN über eine `versionID` verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine `versionID`verfügen.
When the resource last changed - e.g. when the version changed.
Alle von einem Server bereitgestellten Ressourcen SOLLEN über ein `lastUpdate` verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über ein `lastUpdate`verfügen.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
Verweis auf die Regeln, nach denen die Ressource erstellt wurde
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Begründung Constraint: In ISiK existiert kein Use-Case für dieses Element. Da es sich um ein Modifying Element handelt, wird es daher ausgeschlossen. Darüber hinaus werden die Regeln als URI vorgehalten. Dies führt dazu, dass sich hinter der URI eine beliebige Menge an Regeln befinden kann; wodurch nicht sichergestellt werden kann, dass alle Clients die Regeln korrekt interpretieren können.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
This condition has an unspecified relationship with another condition.
Die Deutschen Kodierrichtlinien und die 'German Modification' ermöglichen es teilweise, ICD-10-Codierte Diagnosen miteinander zu verknüpfen ('Kreuz-Stern-Ausrufezeichen-Notation'), diese aber dennoch wie eigenständige Diagnosen (mit jeweils eigener Diagnosesicherheit oder -Lokalisation) zu kommunizieren. Daher ist es in Deutschland nicht möglich, dem internationalen Usus zu folgen und verknüpfte Diagnosen als postkoordinierten Code *einer* Condition-Ressource aufzufassen. Statt dessen müssen sie zwei eigenständige Condition-Ressourcen abgebildet werden, die mit Hilfe der `related`-Extension miteinander verknüpft werden. Die Sekundärdiagnose verweist jeweils auf die Primärdiagnose.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it 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 is allowed to 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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.
This is a business identifier, not a resource identifier (see [discussion](http://hl7.org/fhir/R4/resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.
**Begründung MS:** Auch in Stufe 4 sind keine (client-seitigen) schreibenden Operationen für das Erstellen einer Condition-Ressource vorgesehen (siehe CapabilityStatement). Das heißt, entweder führen KISe entsprechende Informationen und exponieren diese, oder es gibt keinen pragmatischen Mechanismus (im ISIK-Kontext), um den Use Case einer zusätzlichen Annotation mittels Client zu erfüllen. Da alle KIS-Hersteller, die sich zu Wort gemeldet haben, eine Befüllung von Condition.clinicalStatus NICHT unterstützen, erscheint das MS nach übergreifender Definition und ein verpflichtender Testfall nicht angemessen. **Einschränkung der übergreifenden MS-Definition:** Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Status einer Diagnose, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch `clinicalStatus` befüllen, sofern die entsprechende Information verfügbar ist. **Hinweis:** Für Diagnosen aus der *ambulanten* Versorgung können die Werte für `clinicalStatus` und `verificationStatus` aus dem [ICD-10-Zusatzkennzeichen für die Diagnosesicherheit](https://www.bfarm.de/DE/Kodiersysteme/Services/Kodierfragen/ICD-10-GM/Allgemeine-Kodierfragen/icd-10-gm-1010.html) abgeleitet werden. Das entsprechende Mapping kann den [Deutschen Basisprofilen](https://simplifier.net/guide/leitfaden-de-basis-r4/ig-markdown-Ressourcen-DiagnosenCondition?version=current) entnommen werden.
This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.
The clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
The verification status to support the clinical status of the condition.
**Einschränkung der übergreifenden MS-Definition:** Die Implementierung dieses Elements ist für Server optional. Die Kennzeichnung als Must-Support erfolgt, da es sich um ein als Modifier-Element markiertes Feld in der Kernspezifikation handelt. Clients, die eine ISiKPatient-Instanz verarbeiten, SOLLEN den Wert dieses Elements vor der weiteren Verarbeitung prüfen. **WICHTIGER Hinweis für Implementierer:** - Alle server-seitigen Implementierungen SOLLEN in der Lage sein, die systemintern möglichen Statuswerte korrekt in FHIR abzubilden, mindestens aber den Status 'confirmed'. - Alle client-seitigen Implementierungen SOLLEN in der Lage sein, sämtliche Status-Codes zu interpretieren und dem Anwender in angemessener Form darstellen zu können.
This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.
The verification status to support or decline the clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value
**Hinweis EHDS:** Im Kontext des Alignments mit dem EHDS und den damit verbundenen Spezifikationen von HL7 Europe, weisen wir darauf hin, dass in der EPS das Element `category` mittels Obligation gefordert wird. Da Obligations im EU Kontext noch nicht final und stabil definiert sind, ergänzen wir kein MS in ISiK Stufe 6.
'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message
A subjective assessment of the severity of the condition as evaluated by the clinician.
**Hinweis EHDS:** Im Kontext des Alignments mit dem EHDS und den damit verbundenen Spezifikationen von HL7 Europe, weisen wir darauf hin, dass in der EPS das Element `severity` mittels Obligation gefordert wird. Da Obligations im EU Kontext noch nicht final und stabil definiert sind, ergänzen wir kein MS in ISiK Stufe 6.
Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value
Identification of the condition, problem or diagnosis.
Diagnosen SOLLEN mindestens entweder mit einem der angebenen standardisierten Codier-Verfahren codiert werden. Ist keine Codierung möglich, MUSS statt dessen eine textuelle Beschreibung der Prozedur angegeben werden. **Begründung Pflichtfeld:** Ist *weder* eine Codierung *noch* eine textuelle Beschreibung vorhanden, besitzt diese Ressource keine medizinische Aussagefähigkeit.
0..1 to account for primarily narrative only resources.
Entweder MUSS eine kodierte Diagnose vorliegen oder eine textuelle Beschreibung. Stattdessen nur Extensions hinzuzufügen (vgl. https://www.hl7.org/fhir/element.html - ele-1), ist explizit nicht erlaubt.
coding.exists().not() implies text.exists()
Identification of the condition or diagnosis.
code 246090004 |Associated finding| (< 404684003 |Clinical finding| MINUS << 420134006 |Propensity to adverse reactions| MINUS << 473010000 |Hypersensitivity condition| MINUS << 79899007 |Drug interaction| MINUS << 69449002 |Drug action| MINUS << 441742003 |Evaluation finding| MINUS << 307824009 |Administrative status| MINUS << 385356007 |Tumor stage finding|) OR < 413350009 |Finding with explicit context| OR < 272379006 |Event|
A reference to a code defined by a terminology system.
**Hinweis EHDS:** In der HL7 Europe EPS und HDR Spezifikation ist ein Binding von Snomed-CT mit der Stärke preferred gesetzt. Dies schließt sich nicht mit der hier vorgenommenen Profilierung aus, und auch eine reine ICD-10 Abbildung spricht nicht gegen diese Anforderung. Allerdings möchten wir darauf hinweisen, dass es in Zukunft möglicherweise sinnvoll sein könnte, die Nutzung von SNOMED-CT Kodierung zur Darstellung einer Diagnose zu nutzen, um die Interoperabilität mit der EPS zu erhöhen.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Optional Extension Element - found in all resources.
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
**Begründung MS:** Bei ICD-10-codierten Diagnosen an paarigen Organen oder Körperteilen müssen die Zusatzkennzeichen für die Seitigkeit (R, L oder B) angeben werden. **Hinweis EHDS:** Im Kontext des Alignments mit dem EHDS und den damit verbundenen Spezifikationen von HL7 Europe, wird für die Kodierung der Lateralität aktuell die Nutzung einer BodyStructure-Ressource inkl. einer Snomet-CT Kodierung diskutiert. Siehe [bodyStructure-eu-core](https://hl7.eu/fhir/base/StructureDefinition-bodyStructure-eu-core.html).
The identification of the code system that defines the meaning of the symbol in the code.
Motivation MS: URL des CodeSystems des kodierten Wertes.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
Bie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt.
Motivation MS: Version des kodierten Wertes.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Motivation MS: Kodierter Wert aus einem CodeSystem.
Need to refer to a particular code in the system.
In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A representation of the meaning of the code in the system, following the rules of the system.
Motivation MS: Anzeigename des kodierten Wertes.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Die Jahresversion von Alpha-ID. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
Bie Verwendung von Alpha-ID ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von Alpha-ID ein neues Codesystem darstellt.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
The anatomical location where this condition manifests itself.
**Begründung MS:** Harmonisierung mit KBV-Profil (KBV_PR_Base_Condition_Diagnosis)
Codes describing anatomical locations. May include laterality.
< 442083009 |Anatomical or acquired body structure|
Referenz auf eine BodyStructure-Ressource
Record details about the anatomical location of a specimen or body part. This resource may be used when a coded concept does not provide the necessary detail needed for the use case.
Im Kontext des Allingments mit dem EHDS und den damit verbundenen Spezifikationen von HL7 Europe wurde diese Extenion hinzugefügt. Es besteht aber noch keine Must-Support Anforderung, da die Abbildung der Lateralität noch in der Diskussion ist und somit keine klare Vorgabe für die Nutzung der Extension gegeben werden kann. Sobald dies geklärt ist, wird die Anforderung entsprechend angepasst. Eine referenzierte BodyStructure-Ressource sollte valide gegen [bodyStructure-eu-core](https://hl7.eu/fhir/base/StructureDefinition-bodyStructure-eu-core.html) sein.
Indicates the patient or group who the condition record is associated with.
**Begründung Must-Support:** Ein Patientenbezug der Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Group is typically used for veterinary or public health use cases.
A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.
**Begründung MS:** Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu [ISiKPatient](https://gematik.de/fhir/isik/StructureDefinition/ISiKPatient) sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Type the reference refers to (e.g. "Patient")
The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).
This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.
Aa resource (or, for logical models, the URI of the logical model).
Logical reference, when literal reference is not known
An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.
When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
Plain text narrative that identifies the resource in addition to the resource reference.
This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
The Encounter during which this Condition was created or to which the creation of this record is tightly associated.
**Begründung Must-Support:** Ein Aufenthaltsbezug der Diagnose MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
**Begründung Pflichtfeld:** Die Verlinkung auf eine Encounter-Ressource dient der technischen Zuordnung der Dokumentation zu einem Aufenthalt und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. **WICHTIGER Hinweis für Implementierer:** Die Zuordnung MUSS auf einen Encounter der Ebene "Abteilungskontakt" (siehe hierzu Basismodul > UseCases > Abbildung des Konstruktes "Fall") erfolgen. Bei der Auswahl des Encounters ist zu beachten, dass unter einer (Abrechnungs-)"Fallnummer" (hier: `Encounter.account`) unter Umständen mehrere Encounter gruppiert sein können (z.B. stationärer Besuch mit mehreren vor- und nachstationären Aufenthalten.) Im ISik Kontext MUSS die referenzierte Ressource konform zu [ISiKKontaktGesundheitseinrichtung](https://gematik.de/fhir/isik/StructureDefinition/ISiKKontaktGesundheitseinrichtung) sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Estimated or actual date or date-time the condition began, in the opinion of the clinician.
Datum oder Alter/Lebensphase des Erkrankungsbeginns **Begründung MS:** Die Kenntnis des Erkrankungszeitraumes ist wichtig für die korrekte Einschätzung der medizinischen Relevanz einer Erkraknung. **Einschränkung der übergreifenden MS-Definition:** Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Erkrankungszeitraumes, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch klinischen Status (`active`/`inactive`/`resolved`...) der Diagnose korrekt angeben, sofern die Information verfügbar ist.
.effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
Alternative Angabe, wenn genauere Eingrenzungen des Zeitraums nicht möglich sind, insbesondere im Kontext anamnestischer Diagnosen
Numerical value (with implicit precision)
The value of the measured amount. The value includes an implicit precision in the presentation of the value.
The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
Precision is handled implicitly in almost all cases of measurement.
PQ.value, CO.value, MO.value, IVL.high or IVL.low depending on the value
< | <= | >= | > - how to understand the value
How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.
Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.
If there is no comparator, then there is no modification of the value
This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
How the Quantity should be understood and represented.
There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.
The identification of the system that provides the coded form of the unit.
Need to know the system that defines the coded form of the unit.
CO.codeSystem, PQ.translation.codeSystem
A computer processable form of the unit in some unit representation system.
The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.
Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.
PQ.code, MO.currency, PQ.translation.code
The date or estimated date that the condition resolved or went into remission. This is called "abatement" because of the many overloaded connotations associated with "remission" or "resolution" - Conditions are never really resolved, but they can abate.
Ende des klinisch relevanten Zeitraums der Diagnose **Begründung MS:** Die Kenntnis des Erkrankungszeitraumes ist wichtig für die korrekte Einschätzung der medizinischen Relevanz einer Erkraknung. **Einschränkung der übergreifenden MS-Definition:** Verfügt ein bestätigungsrelevantes System nicht über die Datenstruktur zur Hinterlegung des Erkrankungszeitraumes, so MUSS dieses System die Information NICHT abbilden. Das System MUSS jedoch klinischen Status (`active`/`inactive`/`resolved`...) der Diagnose korrekt angeben, sofern die Information verfügbar ist.
.effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
Klinische relevanter Zeitraum Ende als Alter
Klinische relevanter Zeitraum Ende als Datum
The recordedDate represents when this particular Condition record was created in the system, which is often a system-generated date.
Datum, an dem die Diagnose dokumentiert wurde. **Begründung Pflichtfeld:** Das Dokumentationsdatum der Diagnose MUSS zu Qualitätssicherungszwecken angegeben werden. Dies ist das fachliche Dokumentationsdatum, nicht zu verwechseln mit der technischen Anlage des Datensatzes im Primärsystem. Diese beiden Daten können jedoch identisch sein. **Hinweis:** Das Recorded Date MUSS mindestens auf den Monat genau angegeben werden.
Individual who recorded the record and takes responsibility for its content.
Individual who is making the condition statement.
Clinical stage or grade of a condition. May include formal severity assessments.
exists(f:summary) or exists(f:assessment)
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
Extensions that cannot be ignored even if unrecognized
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).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
Codes describing condition stages (e.g. Cancer stages).
Reference to a formal record of the evidence on which the staging assessment is based.
The kind of staging, such as pathological or clinical staging.
Codes describing the kind of condition staging (e.g. clinical or pathological).
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]
Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.
The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
.outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
A manifestation or symptom that led to the recording of this condition.
Codes that describe the manifestation or symptoms of a condition.
Links to other relevant information, including pathology reports.
Additional information about the Condition. This is a general notes/comments entry for description of the Condition, its diagnosis and prognosis.
Ergänzende Hinweise und Anmerkungen zur Diagnose
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value