description: Profile for clinical impressions in the context of rare diseases. This profile captures clinical assessments and suspected diagnoses based on phenotypic findings and symptoms.
package_name: de.medizininformatikinitiative.kerndatensatz.seltene
derivation: constraint
name: MII_PR_Seltene_ClinicalImpression
type: ClinicalImpression
elements:
  description: {short: Zusammenfassung der klinischen Beurteilung, mustSupport: true, index: 5}
  date: {short: Wann die Beurteilung dokumentiert wurde, mustSupport: true, index: 18}
  meta: {mustSupport: true, index: 1}
  investigation:
    short: Eine oder mehrere Untersuchungsserien
    mustSupport: true
    index: 20
    elements:
      code: {short: 'Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde', mustSupport: true, index: 21}
      item:
        type: Reference
        short: Unters
        refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory', 'http://hl7.org/fhir/StructureDefinition/Observation', 'http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse', 'http://hl7.org/fhir/StructureDefinition/RiskAssessment']
        index: 22
  supportingInfo:
    type: Reference
    short: Unterstützende Informationen
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/DocumentReference', 'http://hl7.org/fhir/StructureDefinition/Observation']
    index: 28
  encounter: {mustSupport: true, index: 7}
  problem: {short: Relevante Probleme/Erkrankungen, mustSupport: true, index: 19}
  note: {short: Zusätzliche Anmerkungen, mustSupport: true, index: 29}
  summary: {short: Zusammenfassung der klinischen Beurteilung, mustSupport: true, index: 23}
  effective[x]:
    elements:
      start: {index: 16}
      end: {index: 17}
  effectiveDateTime:
    type: dateTime
    choiceOf: effective
    index: 12
    slicing:
      slices:
        effectiveDateTime:
          match: {}
          schema: {type: dateTime, choiceOf: effective, index: 12}
          min: 0
          max: 1
  status:
    short: Status der klinischen Beurteilung
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/clinicalimpression-status'}
    mustSupport: true
    index: 3
  effective:
    choices: [effectivePeriod]
    index: 14
    slicing:
      slices:
        effectivePeriod:
          match: {}
          schema:
            choices: [effectivePeriod]
            index: 14
          min: 0
          max: 1
  id: {mustSupport: true, index: 0}
  code: {short: Art der klinischen Beurteilung, mustSupport: true, index: 4}
  identifier: {mustSupport: true, index: 2}
  finding:
    short: Klinische Befunde der Untersuchung
    mustSupport: true
    index: 24
    elements:
      itemCodeableConcept:
        short: Klinischer Befund
        binding: {strength: extensible, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/ValueSet/mii-vs-seltene-hpo-phenotypic-observation-codes'}
        index: 25
      itemReference:
        type: Reference
        short: Referenz auf klinischen Befund
        refers: ['http://hl7.org/fhir/StructureDefinition/Condition', 'http://hl7.org/fhir/StructureDefinition/Observation']
        index: 26
      basis: {short: Grundlage für den Befund, index: 27}
  subject:
    type: Reference
    short: Patient, der beurteilt wird
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    index: 6
  effectivePeriod:
    type: Period
    choiceOf: effective
    index: 15
    slicing:
      slices:
        effectivePeriod:
          match: {}
          schema: {type: Period, choiceOf: effective, index: 15}
          min: 0
          max: 1
package_version: 2026.0.0-ballot
class: profile
kind: resource
url: https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression
base: http://hl7.org/fhir/StructureDefinition/ClinicalImpression
version: 2026.0.0-ballot