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 |
| 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. |