{ "description": "Dieses Profil bildet einen Apgar-Score ab.", "_filename": "KBV_PR_Base_Observation_Apgar_Score.json", "package_name": "kbv.basis.with.expansion", "date": "2024-10-24", "derivation": "constraint", "publisher": null, "fhirVersion": "4.0.1", "name": "KBV_PR_Base_Observation_Apgar_Score", "abstract": false, "type": "Observation", "experimental": null, "resourceType": "StructureDefinition", "title": null, "package_version": "1.7.0", "status": "active", "id": "d6cb91c4-7f41-42e1-abda-5dab834added", "kind": "resource", "url": "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Observation_Apgar_Score", "version": "1.7.0", "differential": { "element": [ { "id": "Observation", "path": "Observation", "short": "Apgar-Score", "definition": "Dieses Element beschreibt die Dokumentation eines einzelnen Apgar-Score zu einem definierten Zeitpunkt nach Geburt. Hierbei wird in diesem Basisprofil nur der Gesamt-Apgar-Score modelliert und nicht die einzelnen Teilkomponenten Aussehen, Puls, Gesichtsbewegungen, Aktivität und Respiration." }, { "id": "Observation.status", "path": "Observation.status", "definition": "Hier wird der Status des Eintrages als Code angegeben." }, { "id": "Observation.code", "path": "Observation.code", "definition": "In diesem Element werden Angaben zum Apgar-Score gemacht. Diese werden als codierte Information und/oder als Freitext angegeben." }, { "id": "Observation.code.coding", "min": 2, "path": "Observation.code.coding", "slicing": { "rules": "open", "discriminator": [ { "path": "$this", "type": "value" } ] }, "definition": "Hier wird ein Code aus einem geeigneten Code-System angegeben." }, { "id": "Observation.code.coding:snomed", "max": "1", "min": 1, "path": "Observation.code.coding", "binding": { "strength": "required", "valueSet": "https://fhir.kbv.de/ValueSet/KBV_VS_Base_Apgar_Score_Identifier_SNOMED_CT" }, "sliceName": "snomed", "definition": "In diesem Element wird der Code für den Apgar-Score als SNOMED CT®-Code aus der vorgegebenen Werteliste angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems." }, { "id": "Observation.code.coding:snomed.system", "min": 1, "path": "Observation.code.coding.system" }, { "id": "Observation.code.coding:snomed.version", "min": 1, "path": "Observation.code.coding.version" }, { "id": "Observation.code.coding:snomed.code", "min": 1, "path": "Observation.code.coding.code" }, { "id": "Observation.code.coding:snomed.display", "min": 1, "path": "Observation.code.coding.display" }, { "id": "Observation.code.coding:loinc", "max": "1", "min": 1, "path": "Observation.code.coding", "binding": { "strength": "required", "valueSet": "https://fhir.kbv.de/ValueSet/KBV_VS_Base_Apgar_Score_Identifier_LOINC" }, "sliceName": "loinc", "definition": "In diesem Element wird der Code für den Apgar-Score als LOINC®-Code aus der vorgegebenen Werteliste angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems." }, { "id": "Observation.code.coding:loinc.system", "min": 1, "path": "Observation.code.coding.system" }, { "id": "Observation.code.coding:loinc.version", "min": 1, "path": "Observation.code.coding.version" }, { "id": "Observation.code.coding:loinc.code", "min": 1, "path": "Observation.code.coding.code" }, { "id": "Observation.code.coding:loinc.display", "min": 1, "path": "Observation.code.coding.display" }, { "id": "Observation.code.text", "path": "Observation.code.text", "definition": "Hier wird ein Freitext eingetragen." }, { "id": "Observation.subject", "min": 1, "path": "Observation.subject", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Group", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Location", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Patient|1.7.0", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Device|1.7.0" ] } ] }, { "id": "Observation.focus", "max": "0", "path": "Observation.focus" }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "type": [ { "code": "dateTime" } ], "definition": "Beschreibt den absoluten Zeitpunkt der Bestimmung des Apgar-Scores." }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "type": [ { "code": "CodeableConcept" } ], "slicing": { "rules": "closed", "discriminator": [ { "path": "$this", "type": "type" } ] } }, { "id": "Observation.value[x]:valueCodeableConcept", "max": "1", "min": 0, "path": "Observation.value[x]", "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "required", "valueSet": "https://fhir.kbv.de/ValueSet/KBV_VS_Base_Apgar_Score_Value" }, "sliceName": "valueCodeableConcept", "definition": "Enthält die numerische Angabe des Gesamt-Apgar-Scores in Form eines SNOMED CT®-Codes." }, { "id": "Observation.value[x]:valueCodeableConcept.coding", "max": "1", "min": 1, "path": "Observation.value[x].coding" }, { "id": "Observation.value[x]:valueCodeableConcept.coding.system", "min": 1, "path": "Observation.value[x].coding.system" }, { "id": "Observation.value[x]:valueCodeableConcept.coding.version", "min": 1, "path": "Observation.value[x].coding.version" }, { "id": "Observation.value[x]:valueCodeableConcept.coding.code", "min": 1, "path": "Observation.value[x].coding.code" }, { "id": "Observation.value[x]:valueCodeableConcept.coding.display", "min": 1, "path": "Observation.value[x].coding.display" }, { "id": "Observation.note", "path": "Observation.note", "definition": "Hier werden ergänzende freitextliche Kommentare und Notizen vorgenommen, die nicht durch die strukturierten Datenelemente erfassbar sind." }, { "id": "Observation.note.author[x]", "path": "Observation.note.author[x]", "slicing": { "rules": "open", "discriminator": [ { "path": "$this", "type": "type" } ] }, "definition": "Hier wird die Person angegeben, die die Notiz erstellt hat." }, { "id": "Observation.note.author[x]:authorReference", "max": "1", "min": 0, "path": "Observation.note.author[x]", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson", "http://hl7.org/fhir/StructureDefinition/Organization", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Organization|1.7.0", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_RelatedPerson|1.7.0", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Practitioner|1.7.0", "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_Patient|1.7.0" ] } ], "sliceName": "authorReference", "definition": "Hier wird die Person, die die Notiz erstellt hat, referenziert." }, { "id": "Observation.note.author[x]:authorString", "max": "1", "min": 0, "path": "Observation.note.author[x]", "type": [ { "code": "string" } ], "sliceName": "authorString", "definition": "Hier wird die Person, die die Notiz erstellt hat, referenziert." }, { "id": "Observation.note.time", "path": "Observation.note.time", "definition": "Hier wird der Zeitpunkt angegeben, zu dem die Notiz erstellt wurde." }, { "id": "Observation.note.text", "path": "Observation.note.text", "definition": "Hier wird der eigentliche Text der Notiz eingetragen." }, { "id": "Observation.bodySite", "max": "0", "path": "Observation.bodySite" }, { "id": "Observation.specimen", "max": "0", "path": "Observation.specimen" }, { "id": "Observation.device", "max": "0", "path": "Observation.device" }, { "id": "Observation.component", "max": "0", "path": "Observation.component" } ] }, "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation" }