{ "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": "d0194374-ead5-4ab9-9e2c-dfdfce2dde7e", "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" }