{ "description": "Mit diesem Profil kann eine Diagnose abgebildet werden.", "_filename": "KBVPRMIONFDCondition.json", "package_name": "kbv.mio.patientenkurzakte", "date": null, "derivation": "constraint", "publisher": "Kassenärztliche Bundesvereinigung (KBV)", "fhirVersion": "4.0.1", "name": "KBV_PR_MIO_NFD_Condition", "mapping": [ { "uri": "http://hl7.org/fhir/workflow", "name": "Workflow Pattern", "identity": "workflow" }, { "uri": "http://snomed.info/conceptdomain", "name": "SNOMED CT Concept Domain Binding", "identity": "sct-concept" }, { "uri": "http://hl7.org/v2", "name": "HL7 v2 Mapping", "identity": "v2" }, { "uri": "http://hl7.org/v3", "name": "RIM Mapping", "identity": "rim" }, { "uri": "http://hl7.org/fhir/fivews", "name": "FiveWs Pattern Mapping", "identity": "w5" }, { "uri": "http://snomed.org/attributebinding", "name": "SNOMED CT Attribute Binding", "identity": "sct-attr" } ], "abstract": false, "type": "Condition", "experimental": null, "resourceType": "StructureDefinition", "title": null, "package_version": "1.0.0", "status": "active", "id": "bc58203e-ec15-46fe-aa2d-2a170327c8c3", "kind": "resource", "url": "https://fhir.kbv.de/StructureDefinition/KBV_PR_MIO_NFD_Condition", "version": "1.0.0", "differential": { "element": [ { "id": "Condition", "path": "Condition", "constraint": [ { "key": "Rec1", "human": "Das Dokumentationsdatum soll mindestens mit MM.JJJJ angegeben werden.", "source": "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Diagnosis", "severity": "warning", "expression": "recordedDate.exists() implies recordedDate.toString().length()>=7" } ] }, { "id": "Condition.meta", "min": 1, "path": "Condition.meta" }, { "id": "Condition.meta.versionId", "max": "0", "path": "Condition.meta.versionId" }, { "id": "Condition.meta.lastUpdated", "max": "0", "path": "Condition.meta.lastUpdated" }, { "id": "Condition.meta.source", "max": "0", "path": "Condition.meta.source" }, { "id": "Condition.meta.profile", "max": "1", "min": 1, "path": "Condition.meta.profile", "fixedCanonical": "https://fhir.kbv.de/StructureDefinition/KBV_PR_MIO_NFD_Condition|1.0.0" }, { "id": "Condition.meta.security", "max": "0", "path": "Condition.meta.security" }, { "id": "Condition.meta.tag", "max": "0", "path": "Condition.meta.tag" }, { "id": "Condition.implicitRules", "max": "0", "path": "Condition.implicitRules" }, { "id": "Condition.language", "max": "0", "path": "Condition.language" }, { "id": "Condition.text", "max": "0", "path": "Condition.text" }, { "id": "Condition.contained", "max": "0", "path": "Condition.contained" }, { "id": "Condition.identifier", "max": "0", "path": "Condition.identifier" }, { "id": "Condition.clinicalStatus", "max": "0", "path": "Condition.clinicalStatus" }, { "id": "Condition.verificationStatus", "path": "Condition.verificationStatus", "mustSupport": true }, { "id": "Condition.verificationStatus.coding", "max": "1", "min": 1, "path": "Condition.verificationStatus.coding", "mustSupport": true }, { "id": "Condition.verificationStatus.coding.system", "min": 1, "path": "Condition.verificationStatus.coding.system" }, { "id": "Condition.verificationStatus.coding.version", "min": 1, "path": "Condition.verificationStatus.coding.version" }, { "id": "Condition.verificationStatus.coding.code", "min": 1, "path": "Condition.verificationStatus.coding.code" }, { "id": "Condition.verificationStatus.coding.display", "min": 1, "path": "Condition.verificationStatus.coding.display" }, { "id": "Condition.verificationStatus.coding.display.extension", "path": "Condition.verificationStatus.coding.display.extension", "slicing": { "rules": "closed", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.verificationStatus.coding.display.extension:anzeigenameCategory", "max": "1", "min": 1, "path": "Condition.verificationStatus.coding.display.extension", "type": [ { "code": "Extension", "profile": [ "https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Terminology_German" ] } ], "sliceName": "anzeigenameVerificationStatus", "mustSupport": true }, { "id": "Condition.verificationStatus.coding.display.extension:anzeigenameCategory.extension", "path": "Condition.verificationStatus.coding.display.extension.extension", "slicing": { "rules": "closed", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.verificationStatus.coding.display.extension:anzeigenameCategory.extension:content", "path": "Condition.verificationStatus.coding.display.extension.extension", "sliceName": "content", "mustSupport": true }, { "id": "Condition.verificationStatus.coding.display.extension:anzeigenameCategory.extension:content.value[x]", "path": "Condition.verificationStatus.coding.display.extension.extension.value[x]", "slicing": { "rules": "closed", "discriminator": [ { "path": "$this", "type": "type" } ] }, "mustSupport": true }, { "id": "Condition.verificationStatus.coding.display.extension:anzeigenameCategory.extension:content.value[x]:valueString", "min": 1, "path": "Condition.verificationStatus.coding.display.extension.extension.valueString", "sliceName": "valueString", "definition": "In diesem Attribut sollen die entsprechende deutsche Bezeichnung des Loinc oder Snomed-Codes aus der Conceptmap eingetragen werden, also in diesem Fall den Displaynamen des Targetsystems aus https://fhir.kbv.de/ConceptMap/KBV_CM_MIO_NFD_Verification_Status_German|1.0.0", "mustSupport": true }, { "id": "Condition.verificationStatus.coding.userSelected", "max": "0", "path": "Condition.verificationStatus.coding.userSelected" }, { "id": "Condition.verificationStatus.text", "max": "0", "path": "Condition.verificationStatus.text" }, { "id": "Condition.category", "max": "1", "min": 1, "path": "Condition.category", "mustSupport": true }, { "id": "Condition.category.coding", "max": "1", "min": 1, "path": "Condition.category.coding", "mustSupport": true }, { "id": "Condition.category.coding.system", "min": 1, "path": "Condition.category.coding.system", "fixedUri": "http://snomed.info/sct" }, { "id": "Condition.category.coding.version", "min": 1, "path": "Condition.category.coding.version", "fixedString": "http://snomed.info/sct/900000000000207008/version/20210731" }, { "id": "Condition.category.coding.code", "min": 1, "path": "Condition.category.coding.code", "fixedCode": "439401001" }, { "id": "Condition.category.coding.display", "min": 1, "path": "Condition.category.coding.display", "patternString": "Diagnosis (observable entity)" }, { "id": "Condition.category.coding.display.extension", "path": "Condition.category.coding.display.extension", "slicing": { "rules": "closed", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.category.coding.display.extension:anzeigenameCategory", "max": "1", "min": 1, "path": "Condition.category.coding.display.extension", "type": [ { "code": "Extension", "profile": [ "https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Terminology_German" ] } ], "sliceName": "anzeigenameCategory", "mustSupport": true }, { "id": "Condition.category.coding.display.extension:anzeigenameCategory.extension", "path": "Condition.category.coding.display.extension.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.category.coding.display.extension:anzeigenameCategory.extension:content", "path": "Condition.category.coding.display.extension.extension", "sliceName": "content", "mustSupport": true }, { "id": "Condition.category.coding.display.extension:anzeigenameCategory.extension:content.value[x]", "path": "Condition.category.coding.display.extension.extension.value[x]", "slicing": { "rules": "closed", "discriminator": [ { "path": "$this", "type": "type" } ] }, "mustSupport": true }, { "id": "Condition.category.coding.display.extension:anzeigenameCategory.extension:content.value[x]:valueString", "min": 1, "path": "Condition.category.coding.display.extension.extension.valueString", "sliceName": "valueString", "fixedString": "Diagnose", "mustSupport": true }, { "id": "Condition.category.coding.userSelected", "max": "0", "path": "Condition.category.coding.userSelected" }, { "id": "Condition.category.text", "max": "0", "path": "Condition.category.text" }, { "id": "Condition.severity", "max": "0", "path": "Condition.severity" }, { "id": "Condition.code", "min": 1, "path": "Condition.code", "definition": "In diesem Element wird der Diagnosecode aufgeführt. Dieser kann aus verschiedenen Codiersystem stammen. Jede Diagnose muss mindestens einen Diagnosecode besitzen. Hierbei können die vorgeschlagenen Codiersysteme (ICD, Alpha-ID, SNOMED, ORPHANET) verwendet werden.", "mustSupport": true }, { "id": "Condition.code.coding", "max": "1", "path": "Condition.code.coding", "slicing": { "rules": "open", "discriminator": [ { "path": "system", "type": "value" } ] }, "mustSupport": true }, { "id": "Condition.code.coding:ICD-10-GM", "max": "1", "path": "Condition.code.coding", "type": [ { "code": "Coding", "profile": [ "http://fhir.de/StructureDefinition/CodingICD10GM|0.9.13" ] } ], "sliceName": "ICD-10-GM", "mustSupport": true }, { "id": "Condition.code.coding:ICD-10-GM.extension", "path": "Condition.code.coding.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.code.coding:ICD-10-GM.extension:Primaercode", "max": "1", "path": "Condition.code.coding.extension", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/icd-10-gm-primaercode|0.9.13" ] } ], "sliceName": "Primaercode" }, { "id": "Condition.code.coding:ICD-10-GM.extension:Manifestationscode", "path": "Condition.code.coding.extension", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode|0.9.13" ] } ], "sliceName": "Manifestationscode" }, { "id": "Condition.code.coding:ICD-10-GM.extension:AusrufezeichenCode", "path": "Condition.code.coding.extension", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen|0.9.13" ] } ], "sliceName": "AusrufezeichenCode" }, { "id": "Condition.code.coding:ICD-10-GM.extension:Diagnosesicherheit", "max": "1", "path": "Condition.code.coding.extension", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit|0.9.13" ] } ], "sliceName": "Diagnosesicherheit" }, { "id": "Condition.code.coding:ICD-10-GM.extension:Seitenlokalisation", "max": "1", "path": "Condition.code.coding.extension", "type": [ { "code": "Extension", "profile": [ "http://fhir.de/StructureDefinition/seitenlokalisation|0.9.13" ] } ], "sliceName": "Seitenlokalisation" }, { "id": "Condition.code.coding:alpha-id", "max": "1", "path": "Condition.code.coding", "sliceName": "alpha-id", "mustSupport": true }, { "id": "Condition.code.coding:alpha-id.system", "min": 1, "path": "Condition.code.coding.system", "fixedUri": "http://fhir.de/CodeSystem/dimdi/alpha-id" }, { "id": "Condition.code.coding:alpha-id.version", "min": 1, "path": "Condition.code.coding.version" }, { "id": "Condition.code.coding:alpha-id.code", "min": 1, "path": "Condition.code.coding.code" }, { "id": "Condition.code.coding:snomed-ct", "max": "1", "path": "Condition.code.coding", "binding": { "strength": "required", "valueSet": "https://fhir.kbv.de/ValueSet/KBV_VS_Base_Diagnose_Snomed_CT|1.1.3" }, "sliceName": "snomed-ct", "mustSupport": true }, { "id": "Condition.code.coding:snomed-ct.system", "min": 1, "path": "Condition.code.coding.system", "fixedUri": "http://snomed.info/sct" }, { "id": "Condition.code.coding:snomed-ct.version", "min": 1, "path": "Condition.code.coding.version" }, { "id": "Condition.code.coding:snomed-ct.code", "min": 1, "path": "Condition.code.coding.code" }, { "id": "Condition.code.coding:snomed-ct.display", "min": 1, "path": "Condition.code.coding.display" }, { "id": "Condition.code.coding:snomed-ct.display.extension", "path": "Condition.code.coding.display.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.code.coding:snomed-ct.display.extension:anzeigenameCode", "max": "1", "path": "Condition.code.coding.display.extension", "type": [ { "code": "Extension", "profile": [ "https://fhir.kbv.de/StructureDefinition/KBV_EX_Base_Terminology_German" ] } ], "sliceName": "anzeigenameCode" }, { "id": "Condition.code.coding:snomed-ct.display.extension:anzeigenameCode.extension", "path": "Condition.code.coding.display.extension.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "id": "Condition.code.coding:snomed-ct.display.extension:anzeigenameCode.extension:content", "path": "Condition.code.coding.display.extension.extension", "sliceName": "content" }, { "id": "Condition.code.coding:snomed-ct.display.extension:anzeigenameCode.extension:content.value[x]:valueString", "path": "Condition.code.coding.display.extension.extension.value[x]", "sliceName": "valueString", "definition": "In diesem Attribut sollen die entsprechende deutsche Bezeichnung des Loinc oder Snomed-Codes aus der Conceptmap eingetragen werden. Die entsprechende ConceptMap ist vom ableitetenden Profil anzugeben." }, { "id": "Condition.code.coding:orphanet", "max": "1", "path": "Condition.code.coding", "sliceName": "orphanet" }, { "id": "Condition.code.coding:orphanet.system", "min": 1, "path": "Condition.code.coding.system", "fixedUri": "http://www.orpha.net" }, { "id": "Condition.code.coding:orphanet.version", "min": 1, "path": "Condition.code.coding.version" }, { "id": "Condition.code.coding:orphanet.code", "min": 1, "path": "Condition.code.coding.code" }, { "id": "Condition.code.text", "min": 1, "path": "Condition.code.text", "short": "Diagnoseerläuterung", "definition": "Dieses Element ermöglicht die Angabe von näheren Ausführungen oder zusätzlichen Anmerkungen zu einer Diagnose in Form von Freitext.", "mustSupport": true }, { "id": "Condition.bodySite", "max": "1", "path": "Condition.bodySite", "binding": { "strength": "required", "valueSet": "https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION|1.00" }, "definition": "Über die Körperstelle kann angegeben werden, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (topographische Information).", "mustSupport": true }, { "id": "Condition.bodySite.coding", "max": "1", "min": 1, "path": "Condition.bodySite.coding", "mustSupport": true }, { "id": "Condition.bodySite.coding.system", "min": 1, "path": "Condition.bodySite.coding.system" }, { "id": "Condition.bodySite.coding.version", "min": 1, "path": "Condition.bodySite.coding.version" }, { "id": "Condition.bodySite.coding.code", "min": 1, "path": "Condition.bodySite.coding.code" }, { "id": "Condition.bodySite.coding.display", "min": 1, "path": "Condition.bodySite.coding.display" }, { "id": "Condition.bodySite.coding.userSelected", "max": "0", "path": "Condition.bodySite.coding.userSelected" }, { "id": "Condition.bodySite.text", "max": "0", "path": "Condition.bodySite.text" }, { "id": "Condition.subject", "path": "Condition.subject", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.kbv.de/StructureDefinition/KBV_PR_MIO_NFD_Patient_NFD|1.0.0" ] } ] }, { "id": "Condition.subject.reference", "min": 1, "path": "Condition.subject.reference" }, { "id": "Condition.subject.type", "max": "0", "path": "Condition.subject.type" }, { "id": "Condition.subject.identifier", "max": "0", "path": "Condition.subject.identifier" }, { "id": "Condition.subject.display", "max": "0", "path": "Condition.subject.display" }, { "id": "Condition.encounter", "max": "0", "path": "Condition.encounter" }, { "id": "Condition.onset[x]", "path": "Condition.onset[x]", "type": [ { "code": "dateTime" }, { "code": "string" } ], "slicing": { "rules": "closed", "discriminator": [ { "path": "$this", "type": "type" } ] }, "mustSupport": true }, { "id": "Condition.onset[x]:onsetDateTime", "path": "Condition.onsetDateTime", "type": [ { "code": "dateTime" } ], "sliceName": "onsetDateTime", "mustSupport": true }, { "id": "Condition.onset[x]:onsetString", "path": "Condition.onsetString", "type": [ { "code": "string" } ], "sliceName": "onsetString", "mustSupport": true }, { "id": "Condition.abatement[x]", "max": "0", "path": "Condition.abatement[x]" }, { "id": "Condition.recordedDate", "max": "0", "path": "Condition.recordedDate", "short": "DOKUMENTATIONSDATUM", "definition": "Zeitpunkt, an dem eine Krankheit z. B. durch eine ärztlich tätige Person in diesem Eintrag dokumentiert wurde. Hinweis: Wenn zwischen Feststellung der Diagnose und Dokumentationsdatum nicht unterschieden werden muss, ist das Datum der Feststellung der Diagnose (Diagnosedatum) anzugeben." }, { "id": "Condition.recorder", "max": "0", "path": "Condition.recorder" }, { "id": "Condition.asserter", "path": "Condition.asserter", "type": [ { "code": "Reference", "targetProfile": [ "https://fhir.kbv.de/StructureDefinition/KBV_PR_MIO_NFD_Practitioner_Role_With_Organization|1.0.0" ] } ], "mustSupport": true }, { "id": "Condition.asserter.reference", "min": 1, "path": "Condition.asserter.reference", "mustSupport": true }, { "id": "Condition.asserter.type", "max": "0", "path": "Condition.asserter.type" }, { "id": "Condition.asserter.identifier", "max": "0", "path": "Condition.asserter.identifier" }, { "id": "Condition.asserter.display", "max": "0", "path": "Condition.asserter.display" }, { "id": "Condition.stage", "max": "0", "path": "Condition.stage" }, { "id": "Condition.evidence", "max": "0", "path": "Condition.evidence" }, { "id": "Condition.note", "max": "0", "path": "Condition.note", "short": "FREITEXTBESCHREIBUNG", "definition": "Diagnose im Klartext. Im Bereich der medizinischen Dokumentation sollte die Textbeschreibung obligatorisch sein. Bei der sekundären Übernahme einer kodierten Diagnose aus der Primärdokumentation kann eine Freitextbeschreibung fehlen." } ] }, "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Condition" }