Generated Narrative: StructureDefinition dental-condition Name Flags Card. Type Description & Constraints Condition PraxisConditionDE #xD; Slices for category S 1..* CodeableConcept problem-list-item | encounter-diagnosis Slice: Unordered, Open by pattern:$this #xD; category:dental S 1..1 CodeableConcept problem-list-item | encounter-diagnosis Required Pattern: At least the following #xD; coding 1..* Coding Code defined by a terminology system Fixed Value: (Complex) #xD; system 1..1 uri Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category #xD; code 1..1 code Symbol in syntax defined by the system Fixed Value: dental #xD; display 1..1 string Representation defined by the system Fixed Value: Dental #xD; code S 1..1 CodeableConcept Identification of the condition, problem or diagnosis Binding: ICD10GMVS (1.6.0-ballot) (extensible) #xD; bodySite S 0..* CodeableConcept Körperstelle Binding: Zahnidentifikation nach FDI/ISO 3950 (preferred) #xD; subject S 1..1 Reference(Patient) Who has the condition? #xD; stage S 0..* BackboneElement Stage/grade, usually assessed formally #xD; summary 0..1 CodeableConcept Befundstatus nach KZBV-Zahnschema (f, z, c, k, b, i, etc.) Binding: Zahnärztlicher Befundstatus ValueSet (preferred) #xD; evidence #xD; detail 0..* Reference(Observation) Klinische Belege (Observation, ImagingStudy, DiagnosticReport) #xD; Documentation for this format
Profil für zahnärztliche Diagnosen und Befunde. Nutzt ICD-10-GM und FDI-Zahnschema. Orientiert sich am HL7 Dental Data Exchange IG DentalCondition. Kompatibel mit KBV_PR_Base_Condition_Diagnosis.
Copyright 2026+ cognovis GmbH. Licensed under CC-BY-4.0.
Detailed information about conditions, problems or diagnoses
Hier werden verschiedene Informationen angegeben, die im Zusammenhang mit medizinischen Diagnosen stehen.
Most systems will expect a clinicalStatus to be valued for problem-list-items that are managed over time, but might not need a clinicalStatus for point in time encounter-diagnosis.
Condition.clinicalStatus SHALL be present if verificationStatus is not entered-in-error and category is problem-list-item
clinicalStatus.exists() or verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code = 'entered-in-error').exists() or category.select($this='problem-list-item').empty()
exists(f:clinicalStatus) or exists(f:verificationStatus/f:coding/f:code/@value='entered-in-error') or not(exists(category[@value='problem-list-item']))
If condition is abated, then clinicalStatus must be either inactive, resolved, or remission
abatement.empty() or clinicalStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-clinical' and (code='resolved' or code='remission' or code='inactive')).exists()
not(exists(*[starts-with(local-name(.), 'abatement')])) or exists(f:clinicalStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-clinical' and f:code/@value=('resolved', 'remission', 'inactive')])
Condition.clinicalStatus SHALL NOT be present if verification Status is entered-in-error
verificationStatus.coding.where(system='http://terminology.hl7.org/CodeSystem/condition-ver-status' and code='entered-in-error').empty() or clinicalStatus.empty()
not(exists(f:verificationStatus/f:coding[f:system/@value='http://terminology.hl7.org/CodeSystem/condition-ver-status' and f:code/@value='entered-in-error'])) or not(exists(f:clinicalStatus))
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Das Dokumentationsdatum soll mindestens mit MM.JJJJ angegeben werden.
recordedDate.exists() implies recordedDate.toString().length()>=7
< 243796009 |Situation with explicit context| : 246090004 |Associated finding| = ( ( < 404684003 |Clinical finding| MINUS ( << 420134006 |Propensity to adverse reactions| OR << 473010000 |Hypersensitivity condition| OR << 79899007 |Drug interaction| OR << 69449002 |Drug action| OR << 441742003 |Evaluation finding| OR << 307824009 |Administrative status| OR << 385356007 |Tumor stage finding|)) OR < 272379006 |Event|)
Observation[classCode=OBS, moodCode=EVN, code=ASSERTION, value<Diagnosis]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Hier wird der Zeitpunkt angegeben, an dem die Diagnose bzw. die Erkrankung z. B. durch eine ärztlich tätige Person festgestellt wurde. Dies wird im Folgenden mit Diagnosedatum bezeichnet.
The assertedDate is in the context of the recording practitioner and might not be the same as the recordedDate.
Wenn gesetzt: KI-Provenance via Provenance-Ressource mit AiGeneratedExt, AiProviderExt etc. ist fuer diesen Eintrag dokumentiert.
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Business identifiers assigned to this condition by the performer or other systems which remain constant as the resource is updated and propagates from server to server.
This is a business identifier, not a resource identifier (see [discussion](http://hl7.org/fhir/R4/resource.html#identifiers)). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number.
Allows identification of the condition as it is known by various participating systems and in a way that remains consistent across servers.
active | recurrence | relapse | inactive | remission | resolved
Dieses Element beschreibt den Status einer Diagnose bzw. einer Erkrankung aus klinischer Sicht.
The data type is CodeableConcept because clinicalStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
This element is labeled as a modifier because the status contains codes that mark the condition as no longer active.
The clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="clinicalStatus", moodCode=EVN].value
unconfirmed | provisional | differential | confirmed | refuted | entered-in-error
Hier wird die Diagnosesicherheit dokumentiert.
verificationStatus is not required. For example, when a patient has abdominal pain in the ED, there is not likely going to be a verification status. The data type is CodeableConcept because verificationStatus has some clinical judgment involved, such that there might need to be more specificity than the required FHIR value set allows. For example, a SNOMED coding might allow for additional specificity.
This element is labeled as a modifier because the status contains the code refuted and entered-in-error that mark the Condition as not currently valid.
The verification status to support or decline the clinical status of the condition or diagnosis.
Observation ACT .inboundRelationship[typeCode=COMP].source[classCode=OBS, code="verificationStatus", moodCode=EVN].value
The categorization is often highly contextual and may appear poorly differentiated or not very useful in other contexts.
'problem' if from PRB-3. 'diagnosis' if from DG1 segment in PV1 message
Coding of the severity with a terminology is preferred, where possible.
A subjective assessment of the severity of the condition as evaluated by the clinician.
Can be pre/post-coordinated into value. Or ./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="severity"].value
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
Hier kann der Schweregrad als Code angegeben werden.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
Hier kann der Schweregrad als SNOMED-CT Code angegeben werden.
The identification of the code system that defines the meaning of the symbol in the code.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Identification of the condition, problem or diagnosis
In diesem Element werden Angaben zur Diagnose in Form einer Codierung gemacht. Diese werden als codierte Information und/oder als Freitext angegeben.
0..1 to account for primarily narrative only resources.
code 246090004 |Associated finding| (< 404684003 |Clinical finding| MINUS << 420134006 |Propensity to adverse reactions| MINUS << 473010000 |Hypersensitivity condition| MINUS << 79899007 |Drug interaction| MINUS << 69449002 |Drug action| MINUS << 441742003 |Evaluation finding| MINUS << 307824009 |Administrative status| MINUS << 385356007 |Tumor stage finding|) OR < 413350009 |Finding with explicit context| OR < 272379006 |Event|
Hier wird ein Code aus einem geeigneten Code-System angegeben
Der ICD-Code ist in Deutschland das abrechnungsrelevante Code-System im ambulanten und stationären Bereich. So wird z. B. bei der Abrechnung nach § 301 und § 295 SGB V die Codierung von Diagnosen mittels ICD-10 GM gesetzlich vorgeschrieben. Im ICD-System ist im Gegensatz zu anderen Code-System eine detaillierte Spezifikation von Diagnosen ohne Umwege möglich: die Einordnung der diagnostizierten Erkrankung als Ätiologie oder Manifestation, die Diagnosesicherheit und die Beschreibung des Schweregrades wie auch der Seitenlokalisation. Siehe auch https://www.dimdi.de/dynamic/de/klassifikationen/icd/icd-10-gm/ Bei der Benennung und Struktur der ICD Informationselemente haben wir uns an der FHIR®-technischen Umsetzung entsprechend HL7® Deutschland R4 Extension orientiert. Siehe dazu https://simplifier.net/basisprofil-de-r4/~resources?category=Extension
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
Optional Extension Element - found in all resources.
Zur Spezifizierung von Diagnoseangaben (ICD-10) dürfen die Zusatzkennzeichen für die Seitigkeit (R, L oder B) angegeben werden, d. h. die Angabe ist freiwillig; dies gilt für die stationäre und die ambulante Versorgung.
Die Diagnosesicherheit, d. h. wie sicher die Diagnose im Einzelfall zu werten ist, wird durch ein Zusatzkennzeichen zum ICD-Code angegeben. Für Abrechnungszwecke in der ambulanten Versorgung muss obligatorisch ein Zusatzkennzeichen für die Diagnosesicherheit (A, G, V oder Z) angegeben werden, d. h. die Angabe ist obligatorisch. In der stationären Versorgung sind diese Zusatzkennzeichen für die Angabe der Diagnosesicherheit für Abrechnungszwecke dagegen nicht zulässig.
Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017")
Bie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich. Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt.
In diesem Element wird der Code für die Diagnose angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems, allerdings ohne ein Mehrfachcodierungskennzeichen (z. B. '*', '†' oder '!'). Diese sind in anderen entsprechenden Elementen abzubilden.
Note that FHIR strings SHALL NOT exceed 1MB in size
In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt
In diesem Element wird der Code für die Diagnose angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems.
Bei Alpha-ID-Codes, die zu postkoordinierten ICD-10-Codes gemappt werden, sollten diese nur einmal bei der Primärdiagnose und nicht mehr bei den Sekundärdiagnosen angeben werden (Stichpunkt: related Conditions in FHIR). In Fällen bei denen eine abweichende Diagnosesicherheit zwischen Primär- und Sekundärdiagnose vorhanden ist muss sichergestellt werden, dass die Diagnosesicherheit der Primärdiagnose zu dem assozierten Alpha-ID-Code passt. Siehe der Implementierungsguide (IG) der deutschen Basisprofile von HL7
In diesem Element wird der Code für die Diagnose als SNOMED CT®-Code Code angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems.
In diesem Element wird der Code für die Diagnose als Orphanet Code angegeben, inklusive Anzeigename (Display Name) sowie Name und Version des Code-Systems.
Über die Körperstelle wird angegeben, in welchem Bereich des Körpers eine Krankheit diagnostiziert wurde (topographische Information).
Only used if not implicit in code found in Condition.code. If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension [bodySite](http://hl7.org/fhir/R4/extension-bodysite.html). May be a summary code, or a reference to a very precise definition of the location, or both.
< 442083009 |Anatomical or acquired body structure|
Dieses Element ermöglich die Angabe eines Codes für den Bereich des Körpers, in welchem eine Krankheit diagnostiziert wurde.
Dieses Element ermöglich die Angabe eines SNOMED-CT Codes für den Bereich des Körpers, in welchem eine Krankheit diagnostiziert wurde.
Codes describing anatomical locations. May include laterality.
Gibt den Patienten oder die Gruppe an, mit dem/der der Krankheitsdatensatz verknüpft ist.
Group is typically used for veterinary or public health use cases.
The Encounter during which this Condition was created or to which the creation of this record is tightly associated.
This will typically be the encounter the event occurred within, but some activities may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter. This record indicates the encounter this particular record is associated with. In the case of a "new" diagnosis reflecting ongoing/revised information about the condition, this might be distinct from the first encounter in which the underlying condition was first "known".
.inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
Über den klinisch relevanten Zeitraum wird angezeigt, in welchem Zeitraum bzw. seit wann der/die Patient:in die Diagnose/Erkrankung hatte bzw. hat. Es wird ausgedrückt, seit wann ein/e Patient:in an einer Erkrankung leidet bzw. eine Diagnose hat, indem nur das Startdatum des Zeitraums angegeben wird. Das Startdatum des Zeitraums kann vom Diagnosedatum abweichen. Datumsangaben zu Diagnosen können in unterschiedlicher Präzision vorhanden sein.
Age is generally used when the patient reports an age at which the Condition began to occur.
.effectiveTime.low or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at onset"].value
Estimated or actual date, date-time, or age
Hier wird das Zeintintervall angegeben, ab wann der Patient die Diagnose hatte bzw. unter der Erkrankung leidet/litt.
Hier wird Datum/Zeit für den Beginn der Zeitspanne angegeben.
If the low element is missing, the meaning is that the low boundary is not known.
End time with inclusive boundary, if not ongoing
Hier wird Datum/Zeit für das Ende der Zeitspanne angegeben.
The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.
If the end of the period is missing, it means that the period is ongoing
Hier erfolgt die Angabe der Altersspanne, seit dem der/die Patient:in die Diagnose hat (unter der Erkrankung leidet).
Hier erfolgt die Angabe des ungefähren Alters, ab dem der/die Patient:in die Diagnose hat bzw. unter der Erkrankung leidet.
Hier wird der Beginn der Altersspanne für die Schätzung des Alters angegeben.
If the low element is missing, the low boundary is not known.
Numerical value (with implicit precision)
Hier wird der Wert für die Eintragung des Beginn der Altersspanne für die Schätzung des Alters angegeben.
The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).
Precision is handled implicitly in almost all cases of measurement.
PQ.value, CO.value, MO.value, IVL.high or IVL.low depending on the value
< | <= | >= | > - how to understand the value
Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.
If there is no comparator, then there is no modification of the value
This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value
How the Quantity should be understood and represented.
Hier wird die Einheit für die Eintragung des Beginn der Altersspanne für die Schätzung des Alters angegeben.
There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.
The identification of the system that provides the coded form of the unit.
Need to know the system that defines the coded form of the unit.
CO.codeSystem, PQ.translation.codeSystem
A computer processable form of the unit in some unit representation system.
The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.
Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.
PQ.code, MO.currency, PQ.translation.code
Hier wird das Ende der Altersspanne für die Schätzung des Alters angegeben.
If the high element is missing, the high boundary is not known.
Hier wird der Wert für die Eintragung des Endes der Altersspanne für die Schätzung des Alters angegeben.
Hier wird die Einheit für die Eintragung des Endes der Altersspanne für die Schätzung des Alters angegeben.
Hier wird das Datum angegeben, ab wann der/die Patient:in die Diagnose hatte bzw. unter der Erkrankung leidet/litt.
Hier erfolgt die Angabe des Alters, seit dem der/die Patient:in die Diagnose hat (unter der Erkrankung leidet).
Hier erfolgt die Angabe des Wertes des Alters, seit dem der/die Patient:in die Diagnose hat (unter der Erkrankung leidet).
How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues; e.g. if the comparator is "<" , then the real value is < stated value.
Hier erfolgt die Angabe der Einheit des Alters, seit dem der/die Patient:in die Diagnose hat (unter der Erkrankung leidet).
Hier wird angegeben, bis wann der/die Patient:in die Diagnose/Erkrankung hatte. Bei einer fortbestehenden Diagnose/Erkrankung ist diese Angabe nicht zu übermitteln.
There is no explicit distinction between resolution and remission because in many cases the distinction is not clear. Age is generally used when the patient reports an age at which the Condition abated. If there is no abatement element, it is unknown whether the condition has resolved or entered remission; applications and users should generally assume that the condition is still valid. When abatementString exists, it implies the condition is abated.
.effectiveTime.high or .inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="age at remission"].value or .inboundRelationship[typeCode=SUBJ]source[classCode=CONC, moodCode=EVN].status=completed
Hier wird das Zeitintervall angegeben, bis zu dem der/die Patient:in unter der Erkrankung litt bzw. bis wann der/die Patient:in die Diagnose hatte.
Hier erfolgt die Angabe der Altersspanne, seit der der/die Patient:in die Diagnose nicht mehr hat, bzw. nicht mehr unter der Erkrankung leidet.
Hier erfolgt die Angabe des ungefähren Alters, seit dem der/die Patient:in die Diagnose nicht mehr hat bzw. nicht mehr unter der Erkrankung leidet.
Hier erfolgt die Angabe des Datums, seit dem der/die Patient:in die Diagnose nicht mehr hat, bzw. nicht mehr unter der Erkrankung leidet.
Hier erfolgt die Angabe des Alters, seit dem der/die Patient:in die Diagnose nicht mehr hat, bzw. nicht mehr unter der Erkrankung leidet.
Hier erfolgt die Angabe des Wertes des Alters, seit dem der/die Patient:in die Diagnose nicht mehr hat, bzw. nicht mehr unter der Erkrankung leidet.
Hier erfolgt die Angabe der Einheit des Alters, seit dem der/die Patient:in die Diagnose nicht mehr hat, bzw. nicht mehr unter der Erkrankung leidet.
Hier wird der Zeitpunkt angegeben, 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.
Individual who recorded the record and takes responsibility for its content.
Diagnosesteller (Arzt/Zahnarzt-Vorbehalt -- nur qualifizierte Practitioner)
Wenn angegeben, MUSS ein qualifizierter Practitioner gemaess KBV_PR_Base_Practitioner referenziert werden (Arzt-/Zahnarzt-Vorbehalt: ZHG § 1 Abs. 5, BAeO). MFA/ZFA duerfen Befunde messen (recorder), aber NICHT als asserter referenziert werden.
Clinical stage or grade of a condition. May include formal severity assessments.
exists(f:summary) or exists(f:assessment)
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage/grade"]
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Befundstatus nach KZBV-Zahnschema (f, z, c, k, b, i, etc.)
A simple summary of the stage such as "Stage 3". The determination of the stage is disease-specific.
Reference to a formal record of the evidence on which the staging assessment is based.
The kind of staging, such as pathological or clinical staging.
Codes describing the kind of condition staging (e.g. clinical or pathological).
./inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="stage type"]
Supporting evidence / manifestations that are the basis of the Condition's verification status, such as evidence that confirmed or refuted the condition.
The evidence may be a simple list of coded symptoms/manifestations, or references to observations or formal assessments, or both.
.outboundRelationship[typeCode=SPRT].target[classCode=OBS, moodCode=EVN]
A manifestation or symptom that led to the recording of this condition.
Codes that describe the manifestation or symptoms of a condition.
Klinische Belege (Observation, ImagingStudy, DiagnosticReport)
Verweise auf klinische Belege, die die Diagnose stuetzen: Laborwerte (Observation), Bildgebung (ImagingStudy) oder strukturierte Befundberichte (DiagnosticReport). Mehrere Belege pro evidence-Element moeglich.
Hier werden ergänzende freitextliche Kommentare und Notizen vorgenommen, die nicht durch die strukturierten Datenelemente erfassbar sind.
.inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code="annotation"].value
Individual responsible for the annotation
Hier wird die Person angegeben, die die Notiz erstellt hat.
Organization is used when there's no need for specific attribution as to who made the comment.
Hier wird die Person, die die Notiz erstellt hat, referenziert.
Hier wird die Person, die die Notiz erstellt hat, als Freitext angegeben.
Hier wird der Zeitpunkt angegeben, zu dem die Notiz erstellt wurde.
The annotation - text content (as markdown)
Hier wird der eigentliche Text der Notiz eingetragen.