Aktuella diagnoser

eHN Guidelines:

Data	Element	Description	Preferred Code Systems	Pågående arbeten	Svensk tolkning av informationselementet	Inera	E-hälsomyndigheten	Socialstyrelsen	Systemleverantörer	Regional hälso- och sjukvård	Kommunal hälso- och sjukvård
* ** A.2 Patient summary body data elements
A.2.3	Medical problems			Ur uppdrag: SKR:s och Ineras pågående jämförelser mellan NPÖ och EHDS-kraven för patientöversikt för aktuella diagnoser
	Bedömning
	Täckningsgrad
	Kvalité på informationen
A.2.3.1.1	Problem / diagnosis description	Health conditions affecting the health of the patient and are important to be known for a health professional during a health encounter.	ICD-10* SNOMED CT GPS Orphacode if rare disease is diagnosed
	Bedömning
	Täckningsgrad
	Kvalité på informationen
A.2.3.1.2	Onset date	Date of problem onset	ISO 8601


A.2.3.1.3	Diagnosis assertion status	Assertion about the certainty associated with a diagnosis. Diagnostic and/or clinical evidence of condition.	HL7

Xt-EHR Logical model:

Short	Definition	Min	Max	Type(s)	Binding Strength	Binding Description
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
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	*
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

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