{
  "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.",
  "_filename": "StructureDefinition-mii-pr-seltene-clinical-impression.json",
  "package_name": "de.medizininformatikinitiative.kerndatensatz.seltene",
  "date": null,
  "derivation": "constraint",
  "publisher": "Medizininformatik Initiative",
  "fhirVersion": "4.0.1",
  "name": "MII_PR_Seltene_ClinicalImpression",
  "mapping": [ {
    "uri": "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/LogicalModel/Seltene",
    "name": "Mapping FHIR zu Seltene Erkrankungen Logical Model",
    "identity": "SE-LogicalModel"
  } ],
  "abstract": false,
  "type": "ClinicalImpression",
  "experimental": null,
  "resourceType": "StructureDefinition",
  "title": "MII Profile SE Clinical Impression",
  "package_version": "2026.0.0-ballot",
  "status": "draft",
  "id": "90f5f404-ed69-4ae2-b778-dd2e117ae67b",
  "kind": "resource",
  "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-seltene/StructureDefinition/mii-pr-seltene-clinical-impression",
  "version": "2026.0.0-ballot",
  "differential": {
    "element": [ {
      "id": "ClinicalImpression",
      "path": "ClinicalImpression",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik",
        "comment": "Anamnese und Diagnostik",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.id",
      "path": "ClinicalImpression.id",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.meta",
      "path": "ClinicalImpression.meta",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.identifier",
      "path": "ClinicalImpression.identifier",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.status",
      "path": "ClinicalImpression.status",
      "short": "Status der klinischen Beurteilung",
      "binding": {
        "strength": "required",
        "valueSet": "http://hl7.org/fhir/ValueSet/clinicalimpression-status"
      },
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.code",
      "path": "ClinicalImpression.code",
      "short": "Art der klinischen Beurteilung",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Untersuchungsanlass",
        "comment": "Untersuchungsanlass",
        "identity": "SE-LogicalModel"
      } ],
      "definition": "Kategorisiert die Art der klinischen Beurteilung, die erstellt wird",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.description",
      "path": "ClinicalImpression.description",
      "short": "Zusammenfassung der klinischen Beurteilung",
      "definition": "Eine Zusammenfassung der Beurteilung mit relevanter klinischer Begründung",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.subject",
      "path": "ClinicalImpression.subject",
      "type": [ {
        "code": "Reference",
        "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
      } ],
      "short": "Patient, der beurteilt wird",
      "mapping": [ {
        "map": "Patient",
        "comment": "Patient/Indexpatient",
        "identity": "SE-LogicalModel"
      } ],
      "definition": "Referenz auf den Patienten, für den diese klinische Beurteilung erstellt wird",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.encounter",
      "path": "ClinicalImpression.encounter",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Untersuchungsdatum",
        "comment": "Untersuchungskontakt",
        "identity": "SE-LogicalModel"
      } ],
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.effective[x]",
      "path": "ClinicalImpression.effective[x]",
      "short": "Zeitpunkt der Beurteilung",
      "slicing": {
        "rules": "open",
        "ordered": false,
        "discriminator": [ {
          "path": "$this",
          "type": "type"
        } ]
      },
      "definition": "Der Zeitpunkt oder Zeitraum, über den die klinische Beurteilung gebildet wurde",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.effective[x]:effectiveDateTime",
      "max": "1",
      "min": 0,
      "path": "ClinicalImpression.effective[x]",
      "type": [ {
        "code": "dateTime"
      } ],
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Untersuchungsdatum",
        "comment": "Untersuchungsdatum",
        "identity": "SE-LogicalModel"
      } ],
      "sliceName": "effectiveDateTime"
    }, {
      "id": "ClinicalImpression.effective[x]:effectivePeriod",
      "max": "1",
      "min": 0,
      "path": "ClinicalImpression.effective[x]",
      "type": [ {
        "code": "Period"
      } ],
      "sliceName": "effectivePeriod"
    }, {
      "id": "ClinicalImpression.effective[x]:effectivePeriod.start",
      "path": "ClinicalImpression.effective[x].start",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Untersuchungsdatum",
        "comment": "Beginn der Untersuchung",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.effective[x]:effectivePeriod.end",
      "path": "ClinicalImpression.effective[x].end",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Untersuchungsdatum",
        "comment": "Ende der Untersuchung",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.date",
      "path": "ClinicalImpression.date",
      "short": "Wann die Beurteilung dokumentiert wurde",
      "definition": "Gibt an, wann die klinische Beurteilung dokumentiert wurde",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.problem",
      "path": "ClinicalImpression.problem",
      "short": "Relevante Probleme/Erkrankungen",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.KlinischeDiagnose",
        "comment": "Klinische Diagnose/Verdacht",
        "identity": "SE-LogicalModel"
      } ],
      "definition": "Eine Liste der relevanten Probleme/Erkrankungen für diesen Patienten, die die klinische Beurteilung beeinflussen können",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.investigation",
      "path": "ClinicalImpression.investigation",
      "short": "Eine oder mehrere Untersuchungsserien",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.investigation.code",
      "path": "ClinicalImpression.investigation.code",
      "short": "Art der Untersuchung, die im Rahmen der Beurteilung durchgeführt wurde",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.MethodeDiagnosestellung",
        "comment": "Methode der Diagnosestellung",
        "identity": "SE-LogicalModel"
      } ],
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.investigation.item",
      "path": "ClinicalImpression.investigation.item",
      "type": [ {
        "code": "Reference",
        "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse", "http://hl7.org/fhir/StructureDefinition/FamilyMemberHistory", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/RiskAssessment" ]
      } ],
      "short": "Unters",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Phaenotypisierung",
        "comment": "Durchgeführte Untersuchungen",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.summary",
      "path": "ClinicalImpression.summary",
      "short": "Zusammenfassung der klinischen Beurteilung",
      "definition": "Eine Textzusammenfassung der Beurteilung mit hervorgehobenen wichtigsten Aspekten",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.finding",
      "path": "ClinicalImpression.finding",
      "short": "Klinische Befunde der Untersuchung",
      "definition": "Klinische Befunde, die auf Basis der Untersuchungen festgestellt wurden",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.finding.itemCodeableConcept",
      "path": "ClinicalImpression.finding.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"
      },
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Phaenotypisierung.HPOTerm",
        "comment": "HPO-Term des Symptoms",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.finding.itemReference",
      "path": "ClinicalImpression.finding.itemReference",
      "type": [ {
        "code": "Reference",
        "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/Observation" ]
      } ],
      "short": "Referenz auf klinischen Befund",
      "mapping": [ {
        "map": "AnamneseUndDiagnostik.Phaenotypisierung",
        "comment": "Verweis auf Phänotypisierung",
        "identity": "SE-LogicalModel"
      } ]
    }, {
      "id": "ClinicalImpression.finding.basis",
      "path": "ClinicalImpression.finding.basis",
      "short": "Grundlage für den Befund"
    }, {
      "id": "ClinicalImpression.supportingInfo",
      "path": "ClinicalImpression.supportingInfo",
      "type": [ {
        "code": "Reference",
        "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://hl7.org/fhir/StructureDefinition/Condition", "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
      } ],
      "short": "Unterstützende Informationen",
      "definition": "Informationen, die die klinische Beurteilung unterstützen",
      "mustSupport": true
    }, {
      "id": "ClinicalImpression.note",
      "path": "ClinicalImpression.note",
      "short": "Zusätzliche Anmerkungen",
      "definition": "Kommentare zur Beurteilung, die anderswo nicht erfasst sind",
      "mustSupport": true
    } ]
  },
  "contact": [ {
    "telecom": [ {
      "value": "https://www.medizininformatik-initiative.de",
      "system": "url"
    } ]
  } ],
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ClinicalImpression"
}