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Xt-EHR Logical model:

Short	Definition	Min	Max	Type(s)	Binding Strength	Binding Description	<namn på tjänstekontrakt>	Täckningsgrad (kommentar)	Kvalité på information (kommentar)	Övrig kommentar
B.1.3.2 - Current problems section	Current problems section	0	1	Base
B.1.3.2.1 - Subsection narative	Narative content of the subsection.	0	1	string
B.1.3.2.2 - Current problems	Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter.	1	*	https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSCondition

ShortDefinitionMinMaxType(s)Binding StrengthBinding Description

Täckningsgrad

(kommentar)

Kvalité på information

(kommentar)

Övrig kommentar

Condition modelC.15 - EHDS refined base model for A clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.0*GetDiagnosisC.15.1 - IdentifierCondition identifier0*IdentifierC.15.2 - DescriptionCondition specification in narrative form01NarrativeC.15.3 - CodeCode identifying the condition, problem or diagnosis01CodeableConceptpreferredICD-10*, SNOMED CT, Orphacode if rare disease is diagnosedC.15.4 - Onset dateOnset date of a problem/condition01dateTimeC.15.5 - End dateThe date or estimated date that the condition resolved or went into remission.01dateTimeC.15.6 - CategoryCategory or categories of the problem.0*CodeableConceptC.15.7 - Clinical statusStatus of the condition/problem (active, resolved, inactive, ...)01CodeableConceptpreferredHL7 Condtion-clinical

C.15.8 - Resolution circumstancesDescribes the reason for which the status of the problem changed from current to inactive (e.g. surgical procedure, medical treatment, etc.). This field includes "free text" if the resolution circumstances are not already included in other fields such as surgical procedure, medical device, etc., e.g. hepatic cystectomy (this will be the resolution circumstances for the problem "hepatic cyst" and will be included in surgical procedures).0*CodeableReference(Resource)C.15.9 - SeverityA subjective assessment of the severity of the condition as evaluated by the clinician.01CodeableConceptpreferredHL7 Condtion-severityC.15.10 - Anatomic locationThe anatomical location including laterality where this condition manifests itself.0*CodeableConceptpreferredSNOMED CTC.15.11 - StageStage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used.0*CodeableConceptpreferrede.g. TNM, ICD-O-3, Bi-Rads, Li-Rads, …C.15.12 - SubjectIndicates the patient or group who the condition record is associated with.11Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSGroup)C.15.13 - ParticipantWho or what participated in the activities related to the condition and how they were involved.0*BaseC.15.13.1 - FunctionType of participant involvement.01CodeableConceptpreferredTo be specifiedC.15.13.2 - ActorIdentify the Health Professional who may be specifically related to the condition, e.g., as a preferred contact.11Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional)C.15.14 - External Resourcerelated withIdentify the External Resource which may be specifically relatedto the problem, for example a link between a rare disease problemand the corresponding guidelines.0*uriC.15.15 - Diagnosis assertion statusAssertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition.01CodeableConceptpreferredHL7 Condition-ver-statusRelatedDiagnosisTypeDiagnosisBodyTypeDiagnosisBodyType start-/debutdatum. Möjligen skulle man kunna utöka modellen eller återanvända t.ex. authorTime, men det är inte semantiskt korrekt som onset.DiagnosisBodyType Det motsvarar dock inte full funktionalitet för kategorisering, utan är mer begränsat än ett fritt Category-fält.Finns inget direkt attribut för ”aktiv/inaktiv/avslutad”. Möjligen kan man utöka modellen.Finns inget direkt stöd för att ange ”resolution circumstances”.Indikerar patienten (eller gruppen) som tillståndet tillhörPatientSummaryHeaderType PatientSummaryHeaderType identifierar Vem eller vad har deltagit i aktiviteter relaterade till tillståndet och på vilket sättHealthcareProfessionalTypeTyp av deltagande eller roll (ex. behandlande läkare, ansvarig sjuksköterska, etc.)Detta fält kan ange professionell roll. Kan behöva mappas till koder för specifika roller.Specificerar vem aktören är (ex. vilken vårdpersonal)HealthcareProfessionalType.healthcareProfessionalNameLänkar till externt material kopplat till detta problem/tillstånd (ex. vårdriktlinjer för sällsynta diagnoser)Anger hur säker ställd diagnosen är (ex. differentialdiagnos, arbetsdiagnos, bekräftad, etc.)Ingen eller “assertion status” i UML-modellen.

Kortnamn	Definition	Min	Max	Type(s)	Binding Strength	Binding Description	<namn på tjänstekontrakt>	Övrig kommentar
C.15 - Condition model	EHDS refined base model for a clinical condition, problem, diagnosis, or other event, situation, issue, or clinical concept that has risen to a level of concern.	0	*				GetDiagnosis	Övergripande motsvarighet till ”diagnos” i UML-modellen. Strukturen kretsar kring diagnos men innehåller inte alla attribut som FHIR/EHDS Condition kräver.
C.15.1 - Identifier	Condition identifier	0	*	Identifier
		DiagnosisHeader.documentId	Modellen stödjer en identifierare per diagnos.
C.15.2 - Description	Condition specification in narrative form	0	1	Narrative
		DiagnosisBody.diagnosisCode.originalText	Fritextbeskrivning om kodad information saknas för diagnos.
C.15.3 - Code	Code identifying the condition, problem or diagnosis (ICD-10, SNOMED CT, Orphacode, etc.)	0	1	CodeableConcept	preferred	ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed
DiagnosisBody.diagnosisCode	Används för att ange typ av diagnos.
C.15.4 - Onset date	Onset date of a problem/condition	0	1	dateTime			Ingen	Det finns inget fält som explicit anger
startdatum. Implicit genom första förekomst av dokumentation av en diagnos.
C.15.5 - End date	The date or estimated date that the condition resolved or went into remission.	0	1	dateTime			Ingen	Saknas i UML-modellen.
C.15.6 - Category	Category or categories of the problem.	0	*	CodeableConcept
		DiagnosisBody.chronicDiagnosis samt DiagnosisBody.typeOfDiagnosis	Modellen har ett booleskt attribut chronicDiagnosis som indikerar om diagnosen är kronisk.
Modellen har en kategoriesering av doagnoser som huvuddiagnos eller bidiagnos.
C.15.7 - Clinical status	Status of the condition/problem (active, resolved, inactive, …)	0	1	CodeableConcept (HL7 Condition-clinical)	preferred	HL7 Condtion-clinical	Ingen
Saknar motsvarighet
C.15.8 - Resolution circumstances	Reason for the problem changing from current to inactive (e.g. surgical procedure, medical treatment, etc.)	0	*	CodeableReference(Resource)			Ingen
En diagnos kan relateras till en annan, men ingen koppling mot understödjande eller resulterande dokumentation. .
C.15.9 - Severity	A subjective assessment of the severity of the condition as evaluated by the clinician	0	1	CodeableConcept (HL7 Condition-severity)	preferred	HL7 Condtion-severity	Ingen	Finns inget fält för att ange svårighetsgrad.
C.15.10 - Anatomic location	The anatomical location (inkl. laterality) där tillståndet yttrar sig	0	*	CodeableConcept (SNOMED CT)	preferred	SNOMED CT	Ingen	UML-modellen saknar attribut för anatomisk lokalisation.
C.15.11 - Stage	Stage/grade usually assessed formally using a specific staging/grading system (ex TNM, ICD-O-3, Bi-Rads, Li-Rads, etc.)	0	*	CodeableConcept	preferred		Ingen	Saknas i UML-modellen.
C.15.12 - Subject
Indicates the patient or group who the condition record is associated with.	1	1	Reference(EHDSPatient \| EHDSGroup)
		PatientSummaryHeader.patientId	patientId i
PatientSummaryHeader identifierar vilken patient uppgifterna avser.
C.15.13 - Participant
Who or what participated in the activities related to the condition and how they were involved.	0	*	Bas
		HealthcareProfessional	Objektet beskriver vårdpersonal som är involverad (t.ex. författare). Det täcker en typ av deltagare men inte flera roller samtidigt (om det skulle krävas).
C.15.13.1 - Function
Type of participant involvement.	0	1	CodeableConcept	preferred	To be specified
HealthcareProfessionalType.healthcareProfessionalRoleCode
HealthcareProfessional samt legalAuthenticator	Vårdpersonal ingår alltid i egenskap av dokumentationsansvarig, samt signerande läkare.

C.15.13.2 - Actor
Identify the Health Professional who may be specifically related to the condition, e.g., as a preferred contact.	1	1	Reference(EHDSHealthProfessional)
		HealthcareProfessional	Namn på vårdpersonalen. Andra attribut (ex. healthcareProfessionalCareUnitHSAId) kan också användas för att mer exakt beskriva aktören. Är ej obligatoriskt.
C.15.14 - External Resource related with
Identify the External Resource which may be specifically relatedto the problem, for example a link between a rare disease problemand the corresponding guidelines.	0	*	uri
Möjligen RelatedDiagnosisType	UML-diagrammet visar documentId i RelatedDiagnosisType, men det är inte explicit att detta avser externa resurser. Kan eventuellt återanvändas eller utökas för att peka på externa källor.
		Ingen
C.15.15 - Diagnosis assertion status
Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition.	0	1	CodeableConcept (HL7 Condition-ver-status)	preferred	HL7 Condition-ver-status
legalAuthenticator	Det finns inget fält för att uttrycka diagnossäkerhet
, men uppgifter kan vara signerade eller ej, vilket är en indikation på verifiering.

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