{
  "description": "Dieses Profil beschreibt eine Prozedur in der Medizininformatik-Initiative.",
  "_filename": "StructureDefinition-mii-pr-prozedur-procedure.json",
  "package_name": "de.medizininformatikinitiative.kerndatensatz.prozedur",
  "date": "2024-03-27",
  "derivation": "constraint",
  "publisher": "Medizininformatik Initiative",
  "fhirVersion": "4.0.1",
  "name": "MII_PR_Prozedur_Procedure",
  "abstract": false,
  "type": "Procedure",
  "experimental": null,
  "resourceType": "StructureDefinition",
  "title": "MII PR Prozedur Procedure",
  "_description": {
    "extension": [ {
      "url": "http://hl7.org/fhir/StructureDefinition/translation",
      "extension": [ {
        "url": "lang",
        "valueCode": "de-DE"
      }, {
        "url": "content",
        "valueString": "Eine Prozedur, die an oder für einen Patienten durchgeführt wird oder wurde."
      } ]
    }, {
      "url": "http://hl7.org/fhir/StructureDefinition/translation",
      "extension": [ {
        "url": "lang",
        "valueCode": "en-US"
      }, {
        "url": "content",
        "valueString": "A procedure that is or was performed on or for a patient."
      } ]
    } ]
  },
  "package_version": "2025.0.0-alpha1",
  "status": "active",
  "id": "cc656747-caee-415e-9cc5-bfb22a2d571d",
  "kind": "resource",
  "url": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure",
  "_title": {
    "extension": [ {
      "url": "http://hl7.org/fhir/StructureDefinition/translation",
      "extension": [ {
        "url": "lang",
        "valueCode": "de-DE"
      }, {
        "url": "content",
        "valueString": "Prozedur"
      } ]
    }, {
      "url": "http://hl7.org/fhir/StructureDefinition/translation",
      "extension": [ {
        "url": "lang",
        "valueCode": "en-US"
      }, {
        "url": "content",
        "valueString": "Procedure"
      } ]
    } ]
  },
  "version": "2025.0.0",
  "differential": {
    "element": [ {
      "id": "Procedure",
      "path": "Procedure",
      "constraint": [ {
        "key": "proc-mii-1",
        "human": "Falls die Prozedur per OPS kodiert wird, MUSS eine SNOMED-CT kodierte Category abgebildet werden",
        "source": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure",
        "severity": "error",
        "expression": "code.coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists() implies category.coding.where(system = 'http://snomed.info/sct').exists()"
      } ]
    }, {
      "id": "Procedure.id",
      "path": "Procedure.id",
      "mustSupport": true
    }, {
      "id": "Procedure.meta",
      "path": "Procedure.meta",
      "mustSupport": true
    }, {
      "id": "Procedure.meta.source",
      "path": "Procedure.meta.source",
      "mustSupport": true
    }, {
      "id": "Procedure.meta.profile",
      "path": "Procedure.meta.profile",
      "mustSupport": true
    }, {
      "id": "Procedure.extension",
      "path": "Procedure.extension",
      "mustSupport": true
    }, {
      "path": "Procedure.extension",
      "min": 0,
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Dokumentationsdatum der Prozedur, falls abweichend vom Durchführungsdatum"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "The date the procedure was documented, if different from the performed date"
          } ]
        } ]
      },
      "type": [ {
        "code": "Extension",
        "profile": [ "http://fhir.de/StructureDefinition/ProzedurDokumentationsdatum" ]
      } ],
      "mustSupport": true,
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Dokumentationsdatum"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Recorded date"
          } ]
        } ]
      },
      "sliceName": "Dokumentationsdatum",
      "max": "1",
      "id": "Procedure.extension:Dokumentationsdatum"
    }, {
      "path": "Procedure.extension",
      "min": 0,
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "therapeutisch | palliativ | diagnostisch | präventiv | rehabilitativ | andere"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "therapeutic | palliative | diagnostic | preventive | rehabilitative | other"
          } ]
        } ]
      },
      "type": [ {
        "code": "Extension",
        "profile": [ "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Durchfuehrungsabsicht" ]
      } ],
      "mustSupport": true,
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Durchführungsabsicht"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Intention"
          } ]
        } ]
      },
      "sliceName": "durchfuehrungsabsicht",
      "max": "1",
      "id": "Procedure.extension:durchfuehrungsabsicht"
    }, {
      "id": "Procedure.status",
      "path": "Procedure.status",
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Status"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Status"
          } ]
        } ]
      },
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Vorbereitung | in Arbeit | nicht durchgeführt | pausiert | abgebrochen | abgeschlossen | Eingabe fehlerhaft | unbekannt"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "preparation | in-progress | not-done | on-hold | stopped | completed | entered-in-error | unknown"
          } ]
        } ]
      },
      "mustSupport": true
    }, {
      "id": "Procedure.category",
      "path": "Procedure.category",
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Kategorie"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Category"
          } ]
        } ]
      },
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Diagnostische Maßnahmen | Bildgebende Diagnostik | Operationen | Medikamente | Nichtoperative therapeutische Maßnahmen | Ergänzende Maßnahmen"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Diagnostic procedures | Imaging procedures | Operations | Medications | Non-operative therapeutic procedures | Other procedures"
          } ]
        } ]
      },
      "mustSupport": true
    }, {
      "id": "Procedure.category.coding",
      "path": "Procedure.category.coding",
      "slicing": {
        "rules": "open",
        "discriminator": [ {
          "path": "$this",
          "type": "pattern"
        } ]
      }
    }, {
      "id": "Procedure.category.coding:sct",
      "max": "1",
      "min": 0,
      "path": "Procedure.category.coding",
      "binding": {
        "strength": "preferred",
        "valueSet": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/ValueSet/procedures-category-sct"
      },
      "sliceName": "sct",
      "mustSupport": true,
      "patternCoding": {
        "system": "http://snomed.info/sct"
      }
    }, {
      "id": "Procedure.category.coding:sct.system",
      "min": 1,
      "path": "Procedure.category.coding.system",
      "mustSupport": true
    }, {
      "id": "Procedure.category.coding:sct.code",
      "min": 1,
      "path": "Procedure.category.coding.code",
      "mustSupport": true
    }, {
      "id": "Procedure.code",
      "min": 1,
      "path": "Procedure.code",
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Code"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Code"
          } ]
        } ]
      },
      "constraint": [ {
        "key": "sct-ops-1",
        "human": "Eine Prozedur MUSS mit OPS oder SNOMED-CT kodiert werden.",
        "source": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/StructureDefinition/Procedure",
        "severity": "error",
        "expression": "coding.where(system = 'http://snomed.info/sct').exists() or coding.where(system = 'http://fhir.de/CodeSystem/bfarm/ops').exists()"
      } ],
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Code aus OPS - Operationen- und Prozedurenschlüssel, SNOMED CT oder andere."
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Code from OPS - Operationen- und Prozedurenschlüssel, SNOMED CT or other."
          } ]
        } ]
      },
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding",
      "min": 1,
      "path": "Procedure.code.coding",
      "slicing": {
        "rules": "open",
        "discriminator": [ {
          "path": "$this",
          "type": "pattern"
        } ]
      },
      "mustSupport": true
    }, {
      "path": "Procedure.code.coding",
      "min": 0,
      "type": [ {
        "code": "Coding",
        "profile": [ "http://fhir.de/StructureDefinition/CodingOPS" ]
      } ],
      "mustSupport": true,
      "sliceName": "ops",
      "binding": {
        "strength": "required",
        "valueSet": "http://fhir.de/ValueSet/bfarm/ops"
      },
      "max": "1",
      "id": "Procedure.code.coding:ops",
      "patternCoding": {
        "system": "http://fhir.de/CodeSystem/bfarm/ops"
      }
    }, {
      "id": "Procedure.code.coding:ops.extension:Seitenlokalisation",
      "path": "Procedure.code.coding.extension",
      "sliceName": "Seitenlokalisation",
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding:ops.system",
      "path": "Procedure.code.coding.system",
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding:ops.version",
      "path": "Procedure.code.coding.version",
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding:ops.code",
      "path": "Procedure.code.coding.code",
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding:sct",
      "max": "1",
      "min": 0,
      "path": "Procedure.code.coding",
      "binding": {
        "strength": "required",
        "valueSet": "https://www.medizininformatik-initiative.de/fhir/core/modul-prozedur/ValueSet/procedures-sct"
      },
      "sliceName": "sct",
      "mustSupport": true,
      "patternCoding": {
        "system": "http://snomed.info/sct"
      }
    }, {
      "id": "Procedure.code.coding:sct.system",
      "min": 1,
      "path": "Procedure.code.coding.system",
      "mustSupport": true
    }, {
      "id": "Procedure.code.coding:sct.code",
      "min": 1,
      "path": "Procedure.code.coding.code",
      "mustSupport": true
    }, {
      "id": "Procedure.subject",
      "path": "Procedure.subject",
      "mustSupport": true
    }, {
      "id": "Procedure.performed[x]",
      "min": 1,
      "path": "Procedure.performed[x]",
      "type": [ {
        "code": "dateTime"
      }, {
        "code": "Period"
      } ],
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Durchführungsdatum"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Performed date"
          } ]
        } ]
      },
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Durchführungsdatum oder -zeitraum der Prozedur."
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "The date or period of time the procedure was performed."
          } ]
        } ]
      },
      "mustSupport": true
    }, {
      "id": "Procedure.bodySite",
      "path": "Procedure.bodySite",
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Körperstelle"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Body site"
          } ]
        } ]
      },
      "binding": {
        "strength": "extensible",
        "valueSet": "http://hl7.org/fhir/ValueSet/body-site",
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
          "valueString": "BodySite"
        } ],
        "description": "Codes describing anatomical locations. May include laterality."
      },
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Körperstelle der Prozedur mittels SNOMED CT inklusive Lateralität."
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "The body site of the procedure using SNOMED CT including laterality."
          } ]
        } ]
      },
      "mustSupport": true
    }, {
      "id": "Procedure.note",
      "path": "Procedure.note",
      "_short": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Hinweis"
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Note"
          } ]
        } ]
      },
      "_definition": {
        "extension": [ {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "de-DE"
          }, {
            "url": "content",
            "valueString": "Zusätzliche Informationen zur Prozedur als Freitext."
          } ]
        }, {
          "url": "http://hl7.org/fhir/StructureDefinition/translation",
          "extension": [ {
            "url": "lang",
            "valueCode": "en-US"
          }, {
            "url": "content",
            "valueString": "Additional information about the procedure as free text."
          } ]
        } ]
      },
      "mustSupport": true
    } ]
  },
  "contact": [ {
    "telecom": [ {
      "value": "https://www.medizininformatik-initiative.de",
      "system": "url"
    } ]
  } ],
  "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Procedure"
}