From 6ea61c02a293c7324b7b866f31a5b4a38559339e Mon Sep 17 00:00:00 2001 From: MaxMTheilig Date: Tue, 23 Jan 2024 16:54:14 +0000 Subject: [PATCH] ISiKChronischeNierenerkrankung und ISiKAMTSUseDefinition --- Material/images/diagrams/amts_infomodell.svg | 2 +- Material/images/diagrams/infomodell.svg | 2 +- .../images/src/plantuml/amts_infomodell.puml | 118 +++++++++++++++--- 3 files changed, 106 insertions(+), 16 deletions(-) diff --git a/Material/images/diagrams/amts_infomodell.svg b/Material/images/diagrams/amts_infomodell.svg index 09e8fe1..1e0988d 100644 --- a/Material/images/diagrams/amts_infomodell.svg +++ b/Material/images/diagrams/amts_infomodell.svg @@ -1 +1 @@ -ISiK_BasisISiK_MedikationISiK-Labor (MVP)R4_CoreBasismodul_Stufe_3Dokumentation auf SimplifierISiK Basis Stufe 3ISiKPatientPatientDokumentation auf SimplifierISiK PatientISiKKontaktGesundheitseinrichtungEncounterDokumentation auf SimplifierISiK Kontakt GesundheitseinrichtungISiKPractitionerPractitionerDokumentation auf SimplifierISiK Person im GesundheitsberufISiKDiagnoseConditionDokumentation auf SimplifierISiK DiagnoseBedarf ?klinischer StatusVerifikationsstatusTypKategorieKritikalitätCodeISiKProzedurProcedureDokumentation auf SimplifierISiK ProzedurISiKAngehoerigerRelatedPersonDokumentation auf SimplifierISiK AngehoerigerISiKAllergieAllergyIntoleranceDokumentation auf HL7 OrgAllergy Intoleranceididentifier// External ids for this itemclinicalStatus :AllergyIntoleranceClinicalStatus       // active | inactive | resolvedverificationStatus :AllergyIntoleranceVerificationStatus  //unconfirmed | confirmed | refuted | entered-in-errortype :AllergyIntoleranceType // allergy | intolerance - Underlying mechanism (if known)category :AllergyIntoleranceCategory // food | medication | environment | biologiccriticality:AllergyIntoleranceCriticality // low | high | unable-to-assesscode :AllergyIntoleranceSubstance// Code that identifies the allergy or intolerancepatient : Reference (Patient) // Who the sensitivity is forencounter : Reference (Encounter)// Encounter when the allergy or intolerance was assertedonset[x]// When allergy or intolerance was identified. One of these 5onsetDateTimeonsetAgeonsetPeriodonsetRangeonsetStringrecordedDate // Date first version of the resource instance was recordedrecorder : Reference (Practitioner| PractitionerRole |Patient|RelatedPerson)asserter : Reference (Patient|RelatedPerson|Practitioner| PractitionerRole )lastOccurrencenotereaction //Adverse Reaction Events linked to exposure to substancesubstance :Substance Code//Specific substance or pharmaceutical product considered to be responsible for eventmanifestation :SNOMED CT Clinical Findingsdescriptiononsetseverity :AllergyIntoleranceSeverity// mild | moderate | severe (of event as a whole)exposureRoute :SctRouteOfAdministrationnoteISiKMedikamentMedicationidThis isBlueThis isOrange backgroundcodecoding­PZN :PatternATC-DE :PatternWG14 :Patterntextstatusmanufacturer : Reference (Organization)displayformcodingEDQM :Bindingamountnumerator :Patternvalueunitsystemcodedenominator :PatternvalueunitsystemcodeingredientextensionWirkstofftyp :Extensionitem[x]itemCodeableConceptcoding­ASK :PatternPZN :PatternATC-DE :PatternWG14 :PatterntextitemReference : Reference (Substance|Medication)referenceisActivestrengthnumerator :Patterndenominator :PatternbatchlotNumber ISiKMedikationsInformationMedicationStatementidpartOf : Reference (MedicationAdministration|MedicationDispense| MedicationStatement|Procedure| Observation)statusmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference Reference (Medication)referencesubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartenddateAssertedreasonCodecodingtextreasonReference : Reference (Condition| Observation | DiagnosticReport)referencenotetextdosagetextpatientInstructiontimingeventrepeatsitecodingtextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantityISiKMedikationsListeListidstatus :Bindingmode :Bindingcodecodingmedications :Patternsystemcodedisplaysubject : Reference (Patient)referenceencounter : Reference (Encounter)referencedateentrydateitem : Reference (MedicationStatement)referenceISiKMedikationsVerabreichungMedicationAdministrationidstatussubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartendpeformeractorreferencereasonReference : Reference (Condition| Observation |DiagnosticReport)referencenote :AnnotationtextdosagetextsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :Patterntextdoserate[x]rateRatio :Rationumerator :Patterndenominator :PatternrateQuantity :SimpleQuantityISiKMedikationsVerordnungMedicationRequestidstatusintentdoNotPerformmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference (Medication)referencesubject : Reference (Patient)referenceencounter : Reference (Encounter)referenceauthoredOnrequester : Reference (Practitioner| PractitionerRole |Organization |Patient|RelatedPerson| Device)referencenote :AnnotationtextdosageInstructiontextpatientInstructiontimingeventrepeatsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantitydispenseRequestquantitysubstitutionallowed[x]allowedBooleanISiKMedikationTransactionBundletype : BundleType.Transactionentry linkfullUrlresource search requestmethodurl responseISiKMedikationTransactionResponseBundletype : BundleType.Responseentry linkfullUrlresource search request responsestatuslocationoutcomeSctRouteOfAdministrationValueSetDokumentation auf SimplifierSNOMED CT Route Of AdministrationBeeinhaltet Codes aus SNOMED CT bei denen dasConcept 284009009 (Route Of Administration) istSNOMED_CT 284009009codes :$CS-SCTis-a284009009ISiKLaborErgebnisObservationTBDGFRSerumkreatinRisikomeldungNierenfunktionFoundation_ModulDokumentation auf HL7 OrgHL7 FHIR R4 Core FoundationAllergyIntoleranceTypeValueSetDokumentation auf HL7 OrgAllergy Intolerance TypeDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance TypeZugehöriges Code System of TypeAllergyIntoleranceCategoryValueSetDokumentation auf HL7 OrgAllergy Intolerance CategoryDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance CategoryZugehöriges Code System of CategoryAllergyIntoleranceSubstanceValueSetDokumentation auf HL7 Org[[https://www.hl7.org/fhir/R4/valueset-allergyintolerance-code.htmlAllergyIntolerance Substance/Product, Condition and Negation Codes]]Beeinhaltet alle Substances Codes sowie weitere Codes ausSNOMED CTbei denen Allergien und Unvertraeglichkeiten auftreten.Substance Codescodes :Contained in Substance-Codecodes :$CS-SCTis-a18038007(Propensity to adverse reactions to substance)codes :$CS-SCTis-a267425008(Lactose intolerance)codes :$CS-SCTis-a29736007(Syndrome of carbohydrate intolerance)codes :$CS-SCTis-a340519003(Lysine intolerance)codes :$CS-SCTis-a190753003(Sucrose intolerance)codes :$CS-SCTis-a413427002(Acquired fructose intolerance)codes :$CS-SCTis-a716186003(No known allergy)AllergyIntoleranceCriticalityValueSetDokumentation auf HL7 OrgAllergy Intolerance CriticalityDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance CriticalityZugehöriges Code System of CriticalityAllergyIntoleranceVerificationStatusValueSetDokumentation auf HL7 OrgAllergy Intolerance Verification StatusDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance Verification Status CodesZugehöriges Code System of Verification StatusAllergyIntoleranceClinicalStatusValueSetDokumentation auf HL7 OrgAllergy Intolerance Clinical StatusDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance Clinical Status CodesZugehöriges Code System of Clinical StatusReactionEventSeverityValueSetDokumentation auf HL7 OrgReaction Eventu SeverityDas ValueSet entsprechende Standardset und beeinhatet das komplette Code System der Allergy Intolerance SeverityZugehöriges Code System of Severity \ No newline at end of file +ISiK_VitalparameterUndKoerpermaszeISiK_BasisISiK_MedikationISiK-Labor (MVP)R4_CoreModulVitalparameterUndKoerpermasze_Stufe_3Dokumentation auf SimplifierISiK VitalparameterUndKoerpermasze Stufe 3ISiKKoerpergewichtObservationDokumentation auf SimplifierISiK Körpergewichtsubject : Reference (Patient| Group)encounter : Reference (Encounter)value[x]valueQuantity valueunitsystemcodeBasismodul_Stufe_3Dokumentation auf SimplifierISiK Basis Stufe 3ISiKPatientPatientDokumentation auf SimplifierISiK PatientidbirthDate // relevant fürs Altergender // relevant für Kontraindikation, SchwangerschaftISiKKontaktGesundheitseinrichtungEncounterDokumentation auf SimplifierISiK Kontakt GesundheitseinrichtungISiKKDiagnoseConditionDokumentation auf SimplifierISiK DiagnoseidclinicalStatus // relevant für chronische Erkrakungencode // relevant für Kontraindikation, SchwangerschaftISiKAllergieAllergyIntoleranceDokumentation auf HL7 OrgAllergy Intoleranceididentifier// External ids for this itemclinicalStatus :AllergyIntoleranceClinicalStatus       // active | inactive | resolvedverificationStatus :AllergyIntoleranceVerificationStatus  // unconfirmed | confirmed | refuted | entered-in-errortype :AllergyIntoleranceType // allergy | intolerance - Underlying mechanism (if known)category :AllergyIntoleranceCategory // food | medication | environment | biologiccriticality:AllergyIntoleranceCriticality // low | high | unable-to-assesscode :AllergyIntoleranceSubstance // Code that identifies the allergy or intolerancepatient : Reference (Patient)// Who the sensitivity is forencounter : Reference (Encounter)// Encounter when the allergy or intolerance was assertedonset[x]// When allergy or intolerance was identified. One of these 5onsetDateTimeonsetAgeonsetPeriodonsetRangeonsetStringrecordedDate// Date first version of the resource instance was recordedrecorder : Reference (Practitioner| PractitionerRole |Patient|RelatedPerson)asserter : Reference (Patient|RelatedPerson|Practitioner| PractitionerRole )lastOccurrencenotereaction//Adverse Reaction Events linked to exposure to substancesubstance :Substance Code // Specific substance or pharmaceutical product considered// to be responsible for eventmanifestation :SNOMED CT Clinical Findingsdescriptiononsetseverity :AllergyIntoleranceSeverity// mild | moderate | severe (of event as a whole)exposureRoute :SctRouteOfAdministrationnote class ISiKChronischeNierenerkrankung <Condotion>«(P,#8DA5C4)»{Beispielhafte Profilierung der US-Core Condition im Rahmen derMultiple Chronic Conditions (MCC) eCare Plan, veröffentlicht mit HL7Chronic Kidney Disease ConditionChronic Kidney Disease BeispielISiKAMTSUseDefinitionClinicalUseDefinitionDokumentation auf HL7 OrgCinical Use Definitonidentifier// Business identifier for this issueISiKMedikamentMedicationDokumentation auf SimplifierISiK Medikamentidcode coding­PZN :PatternATC-DE :PatternWG14 :PatterntextingredientextensionWirkstofftyp :Extensionitem[x]itemCodeableConceptcoding­ASK :PatternPZN :PatternATC-DE :PatternWG14 :Patterntext itemReference : Reference (Substance|Medication)referenceISiKMedikationsInformationMedicationStatementDokumentation auf SimplifierISiK Medikationsinformationidmedication[x]medicationReference : Reference (Medication)reference routecodingEDQM :PatternSNOMED-CT :PatterntextSctRouteOfAdministrationValueSetDokumentation auf SimplifierSNOMED CT Route Of AdministrationBeeinhaltet Codes aus SNOMED CT bei denen dasConcept 284009009 (Route Of Administration) istSNOMED_CT 284009009codes :$CS-SCTis-a284009009ISiKLaborBefundDiagnosticReportDokumentation auf HL7 OrgDiagnostic Reportididentifier// Business identifier for reportbasedOn : Reference (CarePlan | ImmunizationRecommendation |MedicationRequest| NutritionOrder |ServiceRequest)// What was requestedstatus :DiagnosticReportStatus   // z.B. amended | unknow | registered | final +category// vernachlässigbarcode:FixedValue // SNOMED Report Name Labor Befundecodingsystem :$CS-SCTversioncode :4241000179101display :Laboratory report (record artifact)subject : Reference (Patient| Group | Device | Location)// The subject of the report - usually, the patientencounter : Reference (Encounter)// Health care event when test orderedeffective[x]// Clinically relevant time/time-period for reporteffectiveDateTimeeffectivePeriodissued :// vernachlässigbarperformer : Reference (Practitioner| PractitionerRole | Organization | CareTeam)// Responsible Diagnostic ServiceresultsInterpreter : Reference (Practitioner| PractitionerRole | Organization | CareTeam)// vernachlässigbarspecimen: Reference (Specimen)// vernachlässigbarresult :Reference (Observation)// ObservationsimagingStudy :Reference (ImagingStudy)  // vernachlässigbarmedia : BackboneElement  // vernachlässigbarconclusion// Clinical conclusion (interpretation) of test resultsconclusionCode:SNOMED CT Clinical Findings  // Codes for the clinical conclusion of test results z.B.AllergyIntolerance.reaction.manifestationpresentedForm :Attachment  // Entire report as issued (PDF)Foundation_ModulDokumentation auf HL7 OrgHL7 FHIR R4 Core FoundationAllergyIntoleranceTypeValueSetDokumentation auf HL7 OrgAllergy Intolerance TypeDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of TypeAllergyIntoleranceCategoryValueSetDokumentation auf HL7 OrgAllergy Intolerance CategoryDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of CategoryAllergyIntoleranceSubstanceValueSetDokumentation auf HL7 OrgAllergyIntolerance Substance, Product Condition and Negation CodesBeeinhaltet alleSubstance Codessowie weitere Codes ausSNOMED CT bei denen Allergien und Unvertraeglichkeiten auftreten.codes :Contained in Substance-Codecodes :$CS-SCTis-a18038007(Propensity to adverse reactions to substance)codes :$CS-SCTis-a267425008(Lactose intolerance)codes :$CS-SCTis-a29736007(Syndrome of carbohydrate intolerance)codes :$CS-SCTis-a340519003(Lysine intolerance)codes :$CS-SCTis-a190753003(Sucrose intolerance)codes :$CS-SCTis-a413427002(Acquired fructose intolerance)codes :$CS-SCTis-a716186003(No known allergy)AllergyIntoleranceCriticalityValueSetDokumentation auf HL7 OrgAllergy Intolerance CriticalityDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of CriticalityAllergyIntoleranceVerificationStatusValueSetDokumentation auf HL7 OrgAllergy Intolerance Verification StatusDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of Verification StatusAllergyIntoleranceClinicalStatusValueSetDokumentation auf HL7 OrgAllergy Intolerance Clinical StatusDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of Clinical StatusReactionEventSeverityValueSetDokumentation auf HL7 OrgReaction Eventu SeverityDas entsprechende Standard-ValueSet beeinhatet das kompletteCode System des zugehörigenCode System of Severity \ No newline at end of file diff --git a/Material/images/diagrams/infomodell.svg b/Material/images/diagrams/infomodell.svg index 261e0a1..6ec370f 100644 --- a/Material/images/diagrams/infomodell.svg +++ b/Material/images/diagrams/infomodell.svg @@ -1 +1 @@ -ISiK_MedikationMII_KerndatensatzR4_CoreISiK_BasisISiKMedikamentMedicationidcodecoding­PZN :PatternATC-DE :PatternWG14 :Patterntextstatusmanufacturer : Reference (Organization)displayformcodingEDQM :Bindingamountnumerator :Patternvalueunitsystemcodedenominator :PatternvalueunitsystemcodeingredientextensionWirkstofftyp :Extensionitem[x]itemCodeableConceptcoding­ASK :PatternPZN :PatternATC-DE :PatternWG14 :PatterntextitemReference : Reference (Substance|Medication)referenceisActivestrengthnumerator :Patterndenominator :PatternbatchlotNumber ISiKMedikationsInformationMedicationStatementidpartOf : Reference (MedicationAdministration|MedicationDispense| MedicationStatement|Procedure| Observation)statusmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference Reference (Medication)referencesubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartenddateAssertedreasonCodecodingtextreasonReference : Reference (Condition| Observation | DiagnosticReport)referencenotetextdosagetextpatientInstructiontimingeventrepeatsitecodingtextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantityISiKMedikationsListeListidstatus :Bindingmode :Bindingcodecodingmedications :Patternsystemcodedisplaysubject : Reference (Patient)referenceencounter : Reference (Encounter)referencedateentrydateitem : Reference (MedicationStatement)referenceISiKMedikationsVerabreichungMedicationAdministrationidstatussubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartendpeformeractorreferencereasonReference : Reference (Condition| Observation |DiagnosticReport)referencenote :AnnotationtextdosagetextsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :Patterntextdoserate[x]rateRatio :Rationumerator :Patterndenominator :PatternrateQuantity :SimpleQuantityISiKMedikationsVerordnungMedicationRequestidstatusintentdoNotPerformmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference (Medication)referencesubject : Reference (Patient)referenceencounter : Reference (Encounter)referenceauthoredOnrequester : Reference (Practitioner| PractitionerRole |Organization |Patient|RelatedPerson| Device)referencenote :AnnotationtextdosageInstructiontextpatientInstructiontimingeventrepeatsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantitydispenseRequestquantitysubstitutionallowed[x]allowedBooleanISiKMedikationTransactionBundletype : BundleType.Transactionentry linkfullUrlresource search requestmethodurl responseISiKMedikationTransactionResponseBundletype : BundleType.Responseentry linkfullUrlresource search request responsestatuslocationoutcomeSctRouteOfAdministrationValueSetDokumentation auf SimplifierSNOMED CT Route Of AdministrationBeeinhaltet Codes aus SNOMED CT bei denen dasConcept 284009009 (Route Of Administration) istSNOMED_CT 284009009codes :$CS-SCTis-a284009009Extension_WirkstofftypDokumentation auf SimplifierMII WirkstofftypFoundation_ModulDokumentation auf HL7 OrgHL7 FHIR R4 Core FoundationBundleDokumentationR4 Bundleidentifiertype : BundleTypetimestamptotallinkrelationurlentrylinkfullUrlresource :ResourcesearchmodescorerequestmethodurlifNoneMatchifModifiedSinceifMatchifNoneExistresponsestatuslocationetaglastModifiedoutcomeListDokumentationR4 Listidentifierstatus : ListStatusmode : ListModetitlecodesubject : Reference (Patient|Group | Device | Location)encounter : Reference (Encounter)datesource : Reference (Practitioner|PractitionerRole |Patient| Device)orderedBynoteentryflagdeleteddateitem : Reference(Any)emptyReasonBasismodul_Stufe_3Dokumentation auf SimplifierISiK Basis Stufe 3ISiKPatientPatientDokumentation auf SimplifierISiK PatientISiKKontaktGesundheitseinrichtungEncounterDokumentation auf SimplifierISiK Kontakt GesundheitseinrichtungISiKPractitionerPractitionerDokumentation auf SimplifierISiK Person im GesundheitsberufISiKDiagnoseConditionDokumentation auf SimplifierISiK DiagnoseISiKProzedurProcedureDokumentation auf SimplifierISiK ProzedurISiKAngehoerigerRelatedPersonDokumentation auf SimplifierISiK Angehoeriger \ No newline at end of file +ISiK_MedikationMII_KerndatensatzR4_CoreISiK_BasisISiKMedikamentMedicationidcodecoding­PZN :PatternATC-DE :PatternWG14 :Patterntextstatusmanufacturer : Reference (Organization)displayformcodingEDQM :Bindingamountnumerator :Patternvalueunitsystemcodedenominator :PatternvalueunitsystemcodeingredientextensionWirkstofftyp :Extensionitem[x]itemCodeableConceptcoding­ASK :PatternPZN :PatternATC-DE :PatternWG14 :PatterntextitemReference : Reference (Substance|Medication)referenceisActivestrengthnumerator :Patterndenominator :PatternbatchlotNumber ISiKMedikationsInformationMedicationStatementidpartOf : Reference (MedicationAdministration|MedicationDispense| MedicationStatement|Procedure| Observation)statusmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference : Reference (Medication)referencesubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartenddateAssertedreasonCodecodingtextreasonReference : Reference (Condition| Observation | DiagnosticReport)referencenotetextdosagetextpatientInstructiontimingeventrepeatsitecodingtextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantityISiKMedikationsListeListidstatus :Bindingmode :Bindingcodecodingmedications :Patternsystemcodedisplaysubject : Reference (Patient)referenceencounter : Reference (Encounter)referencedateentrydateitem : Reference (MedicationStatement)referenceISiKMedikationsVerabreichungMedicationAdministrationidstatussubject : Reference (Patient)referencecontext : Reference (Encounter| EpisodeOfCare)referenceeffective[x]effectiveDateTimeeffectivePeriodstartendpeformeractorreferencereasonReference : Reference (Condition| Observation |DiagnosticReport)referencenote :AnnotationtextdosagetextsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :Patterntextdoserate[x]rateRatio :Rationumerator :Patterndenominator :PatternrateQuantity :SimpleQuantityISiKMedikationsVerordnungMedicationRequestidstatusintentdoNotPerformmedication[x]medicationCodeableConceptcoding­PZN :PatternATC-DE :PatternWG14 :PatterntextmedicationReference (Medication)referencesubject : Reference (Patient)referenceencounter : Reference (Encounter)referenceauthoredOnrequester : Reference (Practitioner| PractitionerRole |Organization |Patient|RelatedPerson| Device)referencenote :AnnotationtextdosageInstructiontextpatientInstructiontimingeventrepeatsitecodingSNOMED-CT :PatterntextroutecodingEDQM :PatternSNOMED-CT :PatterntextdoseAndRatemaxDosePerPeriodnumerator :Patterndenominator :PatternmaxDosePerAdministration :SimpleQuantitydispenseRequestquantitysubstitutionallowed[x]allowedBooleanISiKMedikationTransactionBundletype : BundleType.Transactionentry linkfullUrlresource search requestmethodurl responseISiKMedikationTransactionResponseBundletype : BundleType.Responseentry linkfullUrlresource search request responsestatuslocationoutcomeSctRouteOfAdministrationValueSetDokumentation auf SimplifierSNOMED CT Route Of AdministrationBeeinhaltet Codes aus SNOMED CT bei denen dasConcept 284009009 (Route Of Administration) istSNOMED_CT 284009009codes :$CS-SCTis-a284009009Extension_WirkstofftypDokumentation auf SimplifierMII WirkstofftypFoundation_ModulDokumentation auf HL7 OrgHL7 FHIR R4 Core FoundationBundleDokumentationR4 Bundleidentifiertype : BundleTypetimestamptotallinkrelationurlentrylinkfullUrlresource :ResourcesearchmodescorerequestmethodurlifNoneMatchifModifiedSinceifMatchifNoneExistresponsestatuslocationetaglastModifiedoutcomeListDokumentationR4 Listidentifierstatus : ListStatusmode : ListModetitlecodesubject : Reference (Patient|Group | Device | Location)encounter : Reference (Encounter)datesource : Reference (Practitioner|PractitionerRole |Patient| Device)orderedBynoteentryflagdeleteddateitem : Reference(Any)emptyReasonBasismodul_Stufe_3Dokumentation auf SimplifierISiK Basis Stufe 3ISiKPatientPatientDokumentation auf SimplifierISiK PatientISiKKontaktGesundheitseinrichtungEncounterDokumentation auf SimplifierISiK Kontakt GesundheitseinrichtungISiKPractitionerPractitionerDokumentation auf SimplifierISiK Person im GesundheitsberufISiKDiagnoseConditionDokumentation auf SimplifierISiK DiagnoseISiKProzedurProcedureDokumentation auf SimplifierISiK ProzedurISiKAngehoerigerRelatedPersonDokumentation auf SimplifierISiK Angehoeriger \ No newline at end of file diff --git a/Material/images/src/plantuml/amts_infomodell.puml b/Material/images/src/plantuml/amts_infomodell.puml index 90c7e07..855caf9 100644 --- a/Material/images/src/plantuml/amts_infomodell.puml +++ b/Material/images/src/plantuml/amts_infomodell.puml @@ -13,6 +13,26 @@ ' TODO: ' Vervollständigen im Sinne von: https://github.com/gematik/spec-ISiK-Medikation/blob/rc/main-stufe-4/Material/docs/Medikation%20Abgleich%20bestehende%20Spezifikationen.xlsx +namespace ISiK_VitalparameterUndKoerpermasze { + class ModulVitalparameterUndKoerpermasze_Stufe_3 <<(M,#FFDC36)>>{ + Dokumentation auf Simplifier + [[https://simplifier.net/isik-vitalparameter-und-koerpermasze-v3/~introduction ISiK VitalparameterUndKoerpermasze Stufe 3]] + } + class ISiKKoerpergewicht <<(P,#8DA5C4)>>{ + Dokumentation auf Simplifier + [[https://simplifier.net/isik-vitalparameter-und-koerpermasze-v3/isikkoerpergewicht ISiK Körpergewicht]] + --- + subject : Reference (**Patient** | Group) + encounter : Reference (**Encounter**) + value[x] + |_ valueQuantity + |_ value + |_ unit + |_ system + |_ code + } +} + namespace ISiK_Basis { class Basismodul_Stufe_3 <<(M,#FFDC36)>>{ Dokumentation auf Simplifier @@ -21,16 +41,28 @@ namespace ISiK_Basis { class ISiKPatient <<(P,#8DA5C4)>>{ Dokumentation auf Simplifier [[https://simplifier.net/isik-basis-v3/isikpatient ISiK Patient]] + --- + id + birthDate \n\t// relevant fürs Alter + gender \n\t// relevant für Kontraindikation, Schwangerschaft } class ISiKKontaktGesundheitseinrichtung <<(P,#8DA5C4)>>{ Dokumentation auf Simplifier [[https://simplifier.net/isik-basis-v3/isikkontaktgesundheitseinrichtung ISiK Kontakt Gesundheitseinrichtung]] } + class ISiKKDiagnose <<(P,#8DA5C4)>>{ + Dokumentation auf Simplifier + [[https://simplifier.net/isik-basis-v3/isikdiagnose ISiK Diagnose]] + --- + id + clinicalStatus \n\t// relevant für chronische Erkrakungen + code \n\t// relevant für Kontraindikation, Schwangerschaft + } class ISiKAllergie <<(P,#8DA5C4)>>{ Dokumentation auf HL7 Org [[https://www.hl7.org/fhir/R4/allergyintolerance.html Allergy Intolerance]] - -- + --- id identifier \n\t// External ids for this item clinicalStatus : **AllergyIntoleranceClinicalStatus** \n\t// active | inactive | resolved @@ -60,18 +92,83 @@ namespace ISiK_Basis { |_ severity : **AllergyIntoleranceSeverity** \n\t// mild | moderate | severe (of event as a whole) |_ exposureRoute : **SctRouteOfAdministration** |_ note + + class ISiKChronischeNierenerkrankung <<(P,#8DA5C4)>>{ + Beispielhafte Profilierung der US-Core Condition im Rahmen der \n Multiple Chronic Conditions (MCC) eCare Plan, veröffentlicht mit HL7 + [[https://trifolia-fhir.lantanagroup.com/igs/lantana_hapi_r4/MCC-IG/StructureDefinition-ChronicKidneyDisease.html Chronic Kidney Disease Condition]] + [[https://trifolia-fhir.lantanagroup.com/igs/lantana_hapi_r4/MCC-IG/Condition-f202.html Chronic Kidney Disease Beispiel]] + --- } } namespace ISiK_Medikation { - class ISiKMedikament <<(P,#8DA5C4)>>{ + + class ISiKAMTSUseDefinition <<(P,#8DA5C4)>>{ + Dokumentation auf HL7 Org + [[https://build.fhir.org/clinicalusedefinition.html Cinical Use Definiton]] + --- + identifier \n\t// Business identifier for this issue +' "type" : "", // R! indication | contraindication | interaction | undesirable-effect | warning +' "category" : [{ CodeableConcept }], // A categorisation of the issue, primarily for dividing warnings into subject heading areas such as "Pregnancy", "Overdose" +' "subject" : [{ Reference(ActivityDefinition|BiologicallyDerivedProduct| +' Device|DeviceDefinition|Medication|MedicinalProductDefinition| +' NutritionProduct|PlanDefinition|Substance) }], // The medication, product, substance, device, procedure etc. for which this is an indication, contraindication, interaction, undesirable effect, or warning +' "status" : { CodeableConcept }, // Whether this is a current issue or one that has been retired etc +' "contraindication" : { // I Specifics for when this is a contraindication +' "diseaseSymptomProcedure" : { CodeableReference(ObservationDefinition) }, // The situation that is being documented as contraindicating against this item +' "diseaseStatus" : { CodeableReference(ObservationDefinition) }, // The status of the disease or symptom for the contraindication +' "comorbidity" : [{ CodeableReference(ObservationDefinition) }], // A comorbidity (concurrent condition) or coinfection +' "indication" : [{ Reference(ClinicalUseDefinition) }], // The indication which this is a contraidication for +' "applicability" : { Expression }, // An expression that returns true or false, indicating whether the indication is applicable or not, after having applied its other elements +' "otherTherapy" : [{ // Information about use of the product in relation to other therapies described as part of the contraindication +' "relationshipType" : { CodeableConcept }, // R! The type of relationship between the product indication/contraindication and another therapy +' "treatment" : { CodeableReference(ActivityDefinition| +' BiologicallyDerivedProduct|Medication|MedicinalProductDefinition| +' NutritionProduct|Substance|SubstanceDefinition) } // R! Reference to a specific medication, substance etc. as part of an indication or contraindication +' }] +' }, +' "indication" : { // I Specifics for when this is an indication +' "diseaseSymptomProcedure" : { CodeableReference(ObservationDefinition) }, // The situation that is being documented as an indicaton for this item +' "diseaseStatus" : { CodeableReference(ObservationDefinition) }, // The status of the disease or symptom for the indication +' "comorbidity" : [{ CodeableReference(ObservationDefinition) }], // A comorbidity or coinfection as part of the indication +' "intendedEffect" : { CodeableReference(ObservationDefinition) }, // The intended effect, aim or strategy to be achieved +' // duration[x]: Timing or duration information. One of these 2: +' "durationRange" : { Range }, +' "durationString" : "", +' "undesirableEffect" : [{ Reference(ClinicalUseDefinition) }], // An unwanted side effect or negative outcome of the subject of this resource when being used for this indication +' "applicability" : { Expression }, // An expression that returns true or false, indicating whether the indication is applicable or not, after having applied its other elements +' "otherTherapy" : [{ Content as for ClinicalUseDefinition.contraindication.otherTherapy }] // The use of the medicinal product in relation to other therapies described as part of the indication +' }, +' "interaction" : { // I Specifics for when this is an interaction +' "interactant" : [{ // The specific medication, product, food etc. or laboratory test that interacts +' // item[x]: The specific medication, product, food etc. or laboratory test that interacts. One of these 2: +' "itemReference" : { Reference(BiologicallyDerivedProduct|Medication| +' MedicinalProductDefinition|NutritionProduct|ObservationDefinition|Substance) }, +' "itemCodeableConcept" : { CodeableConcept } +' }], +' "type" : { CodeableConcept }, // The type of the interaction e.g. drug-drug interaction, drug-lab test interaction +' "effect" : { CodeableReference(ObservationDefinition) }, // The effect of the interaction, for example "reduced gastric absorption of primary medication" +' "incidence" : { CodeableConcept }, // The incidence of the interaction, e.g. theoretical, observed +' "management" : [{ CodeableConcept }] // Actions for managing the interaction +' }, +' "population" : [{ Reference(Group) }], // The population group to which this applies +' "library" : [""], // Logic used by the clinical use definition +' "undesirableEffect" : { // I A possible negative outcome from the use of this treatment +' "symptomConditionEffect" : { CodeableReference(ObservationDefinition) }, // The situation in which the undesirable effect may manifest +' "classification" : { CodeableConcept }, // High level classification of the effect +' "frequencyOfOccurrence" : { CodeableConcept } // How often the effect is seen +' }, +' "warning" : { // I Critical environmental, health or physical risks or hazards. For example 'Do not operate heavy machinery', 'May cause drowsiness' +' "description" : "", // A textual definition of this warning, with formatting +' "code" : { CodeableConcept } // A coded or unformatted textual definition of this warning +' } + } + class ISiKMedikament <<(P,#8DA5C4)>>{ Dokumentation auf Simplifier [[https://simplifier.net/isik-medikation-v3/isikmedikament ISiK Medikament]] -- id - This is Blue - This is Orange background code |_ coding­ |_ PZN : **Pattern** @@ -99,15 +196,7 @@ namespace ISiK_Medikation { [[https://simplifier.net/isik-medikation-v3/isikmedikationsinformation ISiK Medikationsinformation]] -- id - partOf : Reference (**MedicationAdministration** | **MedicationDispense** |\n **MedicationStatement** | **Procedure** | Observation) - status medication[x] - |_ medicationCodeableConcept - |_ coding­ - |_ PZN : **Pattern** - |_ ATC-DE : **Pattern** - |_ WG14 : **Pattern** - text |_ medicationReference : Reference (**Medication**) |_ reference |_ route @@ -129,9 +218,10 @@ namespace ISiK_Medikation { } package "ISiK-Labor (MVP)"{ - class ISiKLaborBefunde <<(P,#8DA5C4)>>{ + + class ISiKLaborBefund <<(P,#8DA5C4)>>{ Dokumentation auf HL7 Org - [[http://hl7.org/fhir/R4/diagnosticreport.html DiagnosticReport]] + [[http://hl7.org/fhir/R4/diagnosticreport.html Diagnostic Report]] -- id identifier \n\t // Business identifier for report