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 |
| Short | Definition | Min | Max | Type(s) | Binding Strength | Binding Description | <namn på tjänstekontrakt> | Täckningsgrad (kommentar) | Kvalité på information (kommentar) | Övrig kommentar |
|---|---|---|---|---|---|---|---|---|---|---|
| Condition model | C.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 | * | GetDiagnosis | ||||||
| C.15.1 - Identifier | Condition identifier | 0 | * | Identifier | ||||||
| C.15.2 - Description | Condition specification in narrative form | 0 | 1 | Narrative | ||||||
| C.15.3 - Code | Code identifying the condition, problem or diagnosis | 0 | 1 | CodeableConcept | preferred | ICD-10*, SNOMED CT, Orphacode if rare disease is diagnosed | ||||
| C.15.4 - Onset date | Onset date of a problem/condition | 0 | 1 | dateTime | ||||||
| C.15.5 - End date | The date or estimated date that the condition resolved or went into remission. | 0 | 1 | dateTime | ||||||
| C.15.6 - Category | Category or categories of the problem. | 0 | * | CodeableConcept | ||||||
| C.15.7 - Clinical status | Status of the condition/problem (active, resolved, inactive, ...) | 0 | 1 | CodeableConcept | preferred | HL7 Condtion-clinical | ||||
| C.15.8 - Resolution circumstances | Describes 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 - Severity | A subjective assessment of the severity of the condition as evaluated by the clinician. | 0 | 1 | CodeableConcept | preferred | HL7 Condtion-severity | ||||
| C.15.10 - Anatomic location | The anatomical location including laterality where this condition manifests itself. | 0 | * | CodeableConcept | preferred | SNOMED CT | ||||
| C.15.11 - Stage | Stage/grade usually assessed formally using a specific staging/grading system. Multiple assessment systems could be used. | 0 | * | CodeableConcept | preferred | e.g. TNM, ICD-O-3, Bi-Rads, Li-Rads, … | ||||
| C.15.12 - Subject | Indicates the patient or group who the condition record is associated with. | 1 | 1 | Reference(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSPatient|https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSGroup) | ||||||
| C.15.13 - Participant | Who or what participated in the activities related to the condition and how they were involved. | 0 | * | Base | ||||||
| C.15.13.1 - Function | Type of participant involvement. | 0 | 1 | CodeableConcept | preferred | To be specified | ||||
| 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(https://www.xt-ehr.eu/specifications/fhir/StructureDefinition/EHDSHealthProfessional) | ||||||
| C.15.14 - External Resourcerelated 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 | ||||||
| C.15.15 - Diagnosis assertion status | Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition. | 0 | 1 | CodeableConcept | preferred | HL7 Condition-ver-status | ||||
| 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 | RelatedDiagnosisType.documentId | Modellen stödjer en identifierare per diagnos. | ||
| C.15.2 - Description | Condition specification in narrative form | 0 | 1 | Narrative | DiagnosisBodyType.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 | DiagnosisBodyType.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 start-/debutdatum. Möjligen skulle man kunna utöka modellen eller återanvända t.ex. authorTime, men det är inte semantiskt korrekt som onset. | ||
| 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 | DiagnosisBodyType.chronicDiagnosis | Modellen har ett booleskt attribut chronicDiagnosis som indikerar om diagnosen är kronisk. Det motsvarar dock inte full funktionalitet för kategorisering, utan är mer begränsat än ett fritt Category-fält. | ||
| C.15.7 - Clinical status | Status of the condition/problem (active, resolved, inactive, …) | 0 | 1 | CodeableConcept (HL7 Condition-clinical) | preferred | HL7 Condtion-clinical | Ingen | Finns inget direkt attribut för ”aktiv/inaktiv/avslutad”. Möjligen kan man utöka modellen. |
| 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 | Finns inget direkt stöd för att ange ”resolution circumstances”. | ||
| 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 | Indikerar patienten (eller gruppen) som tillståndet tillhör | 1 | 1 | Reference(EHDSPatient | EHDSGroup) | PatientSummaryHeaderType.patientId | patientId i PatientSummaryHeaderType identifierar vilken patient uppgifterna avser. | ||
| C.15.13 - Participant | Vem eller vad har deltagit i aktiviteter relaterade till tillståndet och på vilket sätt | 0 | * | Bas | HealthcareProfessionalType | 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 | Typ av deltagande eller roll (ex. behandlande läkare, ansvarig sjuksköterska, etc.) | 0 | 1 | CodeableConcept | preferred | To be specified | HealthcareProfessionalType.healthcareProfessionalRoleCode | Detta fält kan ange professionell roll. Kan behöva mappas till koder för specifika roller. |
| C.15.13.2 - Actor | Specificerar vem aktören är (ex. vilken vårdpersonal) | 1 | 1 | Reference(EHDSHealthProfessional) | HealthcareProfessionalType.healthcareProfessionalName | Namn på vårdpersonalen. Andra attribut (ex. healthcareProfessionalCareUnitHSAId) kan också användas för att mer exakt beskriva aktören. | ||
| C.15.14 - External Resource related with | Länkar till externt material kopplat till detta problem/tillstånd (ex. vårdriktlinjer för sällsynta diagnoser) | 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. | ||
| C.15.15 - Diagnosis assertion status | Anger hur säker ställd diagnosen är (ex. differentialdiagnos, arbetsdiagnos, bekräftad, etc.) | 0 | 1 | CodeableConcept (HL7 Condition-ver-status) | preferred | HL7 Condition-ver-status | Ingen | Det finns inget fält för att uttrycka diagnossäkerhet eller “assertion status” i UML-modellen. |