description: Dieses Profil spezifiziert die DGUV-spezifischen Festlegungen für den stationären Operationsbericht als FHIR Composition. Es definiert die verpflichtende Abschnittsstruktur, einschließlich Unfallereignis, Unfallversicherungsträger, Diagnosen und OP-Daten mit ihren jeweiligen Unterabschnitten.
package_name: dguv.oper
derivation: constraint
name: DGUV_OPER_PR_Composition
type: Composition
elements:
  date: {short: Erstellungsdatum des Operationsberichts, mustSupport: true, index: 11}
  meta:
    mustSupport: true
    index: 1
    elements:
      profile:
        mustSupport: true
        pattern: {type: Canonical, value: 'http://fhir.dguv.de/OPER/Composition/DGUV-OPER-PR-Composition'}
        index: 2
    required: [profile]
  section:
    mustSupport: true
    index: 15
    slicing:
      rules: closed
      discriminator:
      - {path: code.coding.code, type: value}
      min: 1
      slices:
        Unfallereignis:
          match:
            code:
              coding: {code: UFER}
          schema:
            mustSupport: true
            _required: true
            index: 16
            elements:
              code:
                mustSupport: true
                index: 17
                elements:
                  coding:
                    mustSupport: true
                    index: 18
                    elements:
                      system:
                        pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                        mustSupport: true
                        index: 19
                      code:
                        pattern: {type: Code, value: UFER}
                        mustSupport: true
                        index: 20
                      display:
                        pattern: {type: String, value: Unfallereignis}
                        mustSupport: true
                        index: 21
                    required: [display, system, code]
                required: [coding]
              entry:
                type: Reference
                mustSupport: true
                refers: ['http://fhir.dguv.de/OPER/Observation/DGUV-OPER-PR-Unfallereignis']
                index: 22
                elements:
                  reference: {mustSupport: true, index: 23}
                required: [reference]
            required: [entry, code]
        Unfallversicherungstraeger:
          match:
            code:
              coding: {code: UVTR}
          schema:
            mustSupport: true
            _required: true
            index: 24
            elements:
              code:
                mustSupport: true
                index: 25
                elements:
                  coding:
                    mustSupport: true
                    index: 26
                    elements:
                      system:
                        pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                        mustSupport: true
                        index: 27
                      code:
                        pattern: {type: Code, value: UVTR}
                        mustSupport: true
                        index: 28
                      display:
                        pattern: {type: String, value: Unfallversicherungsträger}
                        mustSupport: true
                        index: 29
                    required: [display, system, code]
                required: [coding]
              entry:
                type: Reference
                mustSupport: true
                refers: ['http://fhir.dguv.de/OPER/Organization/DGUV-OPER-PR-Unfallversicherungstraeger']
                index: 30
                elements:
                  reference: {mustSupport: true, index: 31}
                required: [reference]
            required: [entry, code]
        Diagnosen:
          match:
            code:
              coding: {code: DGNS}
          schema:
            mustSupport: true
            _required: true
            index: 32
            elements:
              code:
                mustSupport: true
                index: 33
                elements:
                  coding:
                    mustSupport: true
                    index: 34
                    elements:
                      system: {mustSupport: true, index: 35}
                      code:
                        pattern: {type: Code, value: DGNS}
                        mustSupport: true
                        index: 36
                      display:
                        pattern: {type: String, value: Diagnosen}
                        mustSupport: true
                        index: 37
                    required: [display, system, code]
                required: [coding]
              section:
                mustSupport: true
                index: 38
                slicing:
                  rules: open
                  discriminator:
                  - {path: code.coding.code, type: value}
                  min: 1
                  slices:
                    DiagnoseFreitext:
                      match:
                        code:
                          coding: {code: DGFT}
                      schema:
                        mustSupport: true
                        _required: true
                        index: 39
                        elements:
                          code:
                            mustSupport: true
                            index: 40
                            elements:
                              coding:
                                mustSupport: true
                                index: 41
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 42
                                  code:
                                    pattern: {type: Code, value: DGFT}
                                    mustSupport: true
                                    index: 43
                                  display:
                                    pattern: {type: String, value: Diagnose - Freitext}
                                    mustSupport: true
                                    index: 44
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Condition/DGUV-OPER-PR-DiagnoseFreitext']
                            index: 45
                            elements:
                              reference: {mustSupport: true, index: 46}
                            required: [reference]
                        required: [entry, code]
                    DiagnoseStrukturiert:
                      match:
                        code:
                          coding: {code: DGST}
                      schema:
                        mustSupport: true
                        _required: true
                        index: 47
                        elements:
                          code:
                            mustSupport: true
                            index: 48
                            elements:
                              coding:
                                mustSupport: true
                                index: 49
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 50
                                  code:
                                    pattern: {type: Code, value: DGST}
                                    mustSupport: true
                                    index: 51
                                  display:
                                    pattern: {type: String, value: Diagnose - strukturiert}
                                    mustSupport: true
                                    index: 52
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Condition/DGUV-OPER-PR-DiagnoseStrukturiert']
                            index: 53
                            elements:
                              reference: {mustSupport: true, index: 54}
                            required: [reference]
                        required: [entry, code]
            required: [section, code]
        OP-Daten:
          match:
            code:
              coding: {code: OPDT}
          schema:
            mustSupport: true
            _required: true
            index: 55
            elements:
              code:
                mustSupport: true
                index: 56
                elements:
                  coding:
                    mustSupport: true
                    index: 57
                    elements:
                      system:
                        pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                        mustSupport: true
                        index: 58
                      code:
                        pattern: {type: Code, value: OPDT}
                        mustSupport: true
                        index: 59
                      display:
                        pattern: {type: String, value: OP-Daten}
                        mustSupport: true
                        index: 60
                    required: [display, system, code]
                required: [coding]
              section:
                mustSupport: true
                array: true
                min: 3
                index: 61
                slicing:
                  rules: open
                  discriminator:
                  - {path: code.coding.code, type: value}
                  min: 3
                  slices:
                    OpBefundVerlauf:
                      match:
                        code:
                          coding: {code: OPBV}
                      schema:
                        mustSupport: true
                        _required: true
                        index: 62
                        elements:
                          code:
                            mustSupport: true
                            index: 63
                            elements:
                              coding:
                                mustSupport: true
                                index: 64
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 65
                                  code:
                                    pattern: {type: Code, value: OPBV}
                                    mustSupport: true
                                    index: 66
                                  display:
                                    pattern: {type: String, value: OP-Befund und -Verlauf}
                                    mustSupport: true
                                    index: 67
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Observation/DGUV-OPER-PR-OpBefundVerlauf']
                            index: 68
                            elements:
                              reference: {mustSupport: true, index: 69}
                            required: [reference]
                        required: [entry, code]
                    OPProzedur:
                      match:
                        code:
                          coding: {code: OPPD}
                      schema:
                        mustSupport: true
                        _required: true
                        index: 70
                        elements:
                          code:
                            mustSupport: true
                            index: 71
                            elements:
                              coding:
                                mustSupport: true
                                index: 72
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 73
                                  code:
                                    pattern: {type: Code, value: OPPD}
                                    mustSupport: true
                                    index: 74
                                  display:
                                    pattern: {type: String, value: OP Prozedur}
                                    mustSupport: true
                                    index: 75
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Procedure/DGUV-OPER-PR-OPProzedur']
                            index: 76
                            elements:
                              reference: {mustSupport: true, index: 77}
                            required: [reference]
                        required: [entry, code]
                    HistoMibiUntersuchung:
                      match:
                        code:
                          coding: {code: HIMU}
                      schema:
                        mustSupport: true
                        _required: true
                        index: 78
                        elements:
                          code:
                            mustSupport: true
                            index: 79
                            elements:
                              coding:
                                mustSupport: true
                                index: 80
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 81
                                  code:
                                    pattern: {type: Code, value: HIMU}
                                    mustSupport: true
                                    index: 82
                                  display:
                                    pattern: {type: String, value: Histo -/mikrobiologische Untersuchung}
                                    mustSupport: true
                                    index: 83
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Observation/DGUV-OPER-PR-HistoMibiUntersuchung']
                            index: 84
                            elements:
                              reference: {mustSupport: true, index: 85}
                            required: [reference]
                        required: [entry, code]
                    Implantat:
                      match:
                        code:
                          coding: {code: IMPT}
                      schema:
                        mustSupport: true
                        index: 86
                        elements:
                          code:
                            mustSupport: true
                            index: 87
                            elements:
                              coding:
                                mustSupport: true
                                index: 88
                                elements:
                                  system:
                                    pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                                    mustSupport: true
                                    index: 89
                                  code:
                                    pattern: {type: Code, value: IMPT}
                                    mustSupport: true
                                    index: 90
                                  display:
                                    pattern: {type: String, value: Implantat}
                                    mustSupport: true
                                    index: 91
                                required: [display, system, code]
                            required: [coding]
                          entry:
                            type: Reference
                            mustSupport: true
                            refers: ['http://fhir.dguv.de/OPER/Device/DGUV-OPER-PR-Implantat']
                            index: 92
                            elements:
                              reference: {mustSupport: true, index: 93}
                            required: [reference]
                        required: [entry, code]
            required: [code]
        PostoperativeTherapieempfehlung:
          match:
            code:
              coding: {code: POTE}
          schema:
            mustSupport: true
            _required: true
            index: 94
            elements:
              code:
                mustSupport: true
                index: 95
                elements:
                  coding:
                    index: 96
                    elements:
                      system:
                        pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                        mustSupport: true
                        index: 97
                      code:
                        pattern: {type: Code, value: POTE}
                        mustSupport: true
                        index: 98
                      display:
                        pattern: {type: String, value: Postoperative Therapieempfehlung}
                        mustSupport: true
                        index: 99
                    required: [display, system, code]
                required: [coding]
              entry:
                type: Reference
                mustSupport: true
                refers: ['http://fhir.dguv.de/OPER/Observation/DGUV-OPER-PR-PostoperativeTherapieempfehlung']
                index: 100
                elements:
                  reference: {mustSupport: true, index: 101}
                required: [reference]
            required: [entry, code]
        BehandelndeEinrichtung:
          match:
            code:
              coding: {code: BNEN}
          schema:
            mustSupport: true
            _required: true
            index: 102
            elements:
              code:
                mustSupport: true
                index: 103
                elements:
                  coding:
                    mustSupport: true
                    index: 104
                    elements:
                      system:
                        pattern: {type: Uri, value: 'http://fhir.dguv.de/OPER/CodeSystem/DGUV-OPER-CS-CompositionSections'}
                        mustSupport: true
                        index: 105
                      code:
                        pattern: {type: Code, value: BNEN}
                        mustSupport: true
                        index: 106
                      display:
                        pattern: {type: String, value: Behandelnde Einrichtung}
                        mustSupport: true
                        index: 107
                    required: [display, system, code]
                required: [coding]
              entry:
                type: Reference
                mustSupport: true
                refers: ['http://fhir.dguv.de/OPER/Organization/DGUV-OPER-PR-BehandelndeEinrichtung']
                index: 108
                elements:
                  reference: {mustSupport: true, index: 109}
                required: [reference]
            required: [entry, code]
  type:
    short: Kennzeichnung Composition als Operationsbericht
    mustSupport: true
    index: 4
    elements:
      coding:
        mustSupport: true
        index: 5
        elements:
          system:
            short: Code-System mit Formtextvarianten bzw. Berichtstypen
            pattern: {type: Uri, value: 'http://fhir.dguv.de/Basis/CodeSystem/DGUV-Basis-CS-Formtexte'}
            mustSupport: true
            index: 6
          code:
            short: Kürzel des konkreten Berichtstypen
            pattern: {type: Code, value: OPER}
            mustSupport: true
            index: 7
          display:
            short: Bezeichnung des konkreten Berichtstypen
            pattern: {type: String, value: Operationsbericht}
            mustSupport: true
            index: 8
        required: [display, system, code]
    required: [coding]
  title:
    short: Menschenlesbarer Name/Titel des Berichts
    pattern: {type: String, value: Stationärer Operationsbericht}
    mustSupport: true
    index: 14
  author:
    type: Reference
    short: Verweis auf Ersteller des Operationsberichts
    mustSupport: true
    refers: ['http://fhir.dguv.de/OPER/Practitioner/DGUV-OPER-PR-Autor']
    index: 12
    elements:
      reference: {short: Konkreter Verweis auf Ersteller des Operationsberichts, mustSupport: true, index: 13}
    required: [reference]
  status:
    pattern: {type: Code, value: final}
    mustSupport: true
    index: 3
  id: {mustSupport: true, index: 0}
  subject:
    type: Reference
    short: Verweis auf betroffene versicherte Person
    mustSupport: true
    refers: ['http://fhir.dguv.de/OPER/Patient/DGUV-OPER-PR-VersichertePerson']
    index: 9
    elements:
      reference: {short: Konkreter Verweis auf versicherte Person, mustSupport: true, index: 10}
    required: [reference]
package_version: 0.1.0-Kommentierung
class: profile
kind: resource
url: http://fhir.dguv.de/OPER/Composition/DGUV-OPER-PR-Composition
base: http://hl7.org/fhir/StructureDefinition/Composition
version: '0.1'
required: [section, subject, meta]