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 | 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 | 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 | 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. |