[EN] Module Procedure - Version 1.0 - IG

Data Sets incl. Descriptions

The official and accepted version of the information model for the PROCEDURE module can be found on ART-DECOR. To standardize the representation, the information model was additionally mapped as FHIR Logical Model:

LogicalModelProzedur (Prozedur)			Element	Element id Prozedur Short description Das Basismodul Prozeduren umfasst die Beschreibung diagnostischer oder therapeutischer Maßnahmen, die als Leistungskomplexe auch für die Abrechnung dokumentiert und kodiert werden, z.B. Operationen. Definition Base definition for all elements in a resource. Data type Element Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
OPSProzedurKodiert		0..*	BackboneElement	Element id Prozedur.OPSProzedurKodiert Short description Kodierung der durchgeführten Prozedur mittels OPS. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. Data type BackboneElement Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.OPSProzedurKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
VollstaendigerProzedurenkode		0..*	code	Element id Prozedur.OPSProzedurKodiert.VollstaendigerProzedurenkode Short description Der vollständige Prozedurenkode: Tripel aus OPS-Kode, Kodesystem (inkl. Version!) und Katalogtext. Definition A string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Seitenlokalisation		0..*	code	Element id Prozedur.OPSProzedurKodiert.Seitenlokalisation Short description Seitenlokalisation für die durchgeführte Prozedur gemäß DIMDI Definition A string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
SNOMEDProzedurKodiert		0..*	BackboneElement	Element id Prozedur.SNOMEDProzedurKodiert Short description Kodierung der durchgeführten Prozedur mittels SNOMED CT. Definition Base definition for all elements that are defined inside a resource - but not those in a data type. Data type BackboneElement Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
id		0..1	string	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! C	0..*	Extension	There are no (further) constraints on this element Element id Prozedur.SNOMEDProzedurKodiert.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Requirements Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
VollstaendigerProzedurenkode		0..*	code	Element id Prozedur.SNOMEDProzedurKodiert.VollstaendigerProzedurenkode Short description Der vollständige Prozedurenkode: Tripel aus SNOMED-CT-Kode, Kodesystem (Version optional) und Katalogtext. Definition A string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Koerperstelle		0..*	string	Element id Prozedur.Koerperstelle Short description Körperstelle der Prozedur mittels SNOMED CT inkl. Lateralität (R, L, B) Definition A sequence of Unicode characters Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Durchfuehrungsabsicht		0..*	code	Element id Prozedur.Durchfuehrungsabsicht Short description Intention mit der die Prozedur durchgeführt wird Definition A string which has at least one character and no leading or trailing whitespace and where there is no whitespace other than single spaces in the contents Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Durchfuehrungsdatum		0..*	date	Element id Prozedur.Durchfuehrungsdatum Short description Durchführungsdatum der Prozedur Definition A date or partial date (e.g. just year or year + month). There is no time zone. The format is a union of the schema types gYear, gYearMonth and date. Dates SHALL be valid dates. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Dokumentationsdatum		0..*	date	Element id Prozedur.Dokumentationsdatum Short description Dokumentationsdatum der Prozedur Definition A date or partial date (e.g. just year or year + month). There is no time zone. The format is a union of the schema types gYear, gYearMonth and date. Dates SHALL be valid dates. Data type date Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
Freitextbeschreibung		0..*	string	Element id Prozedur.Freitextbeschreibung Short description Prozedur im Klartext Definition A sequence of Unicode characters Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`

It should be noted that the Logical Model aims purely at the mapping of data elements and their description. Used data types and cardinalities are not to be regarded as obligatory. This is finally defined by the FHIR profiles. For each element within the Logical Model there is a 1:1 mapping to an element of a concrete FHIR resource.

Logischer_Datensatz	Beschreibung
Prozedur	Das Basismodul Prozeduren umfasst die Beschreibung diagnostischer oder therapeutischer Maßnahmen, die als Leistungskomplexe auch für die Abrechnung dokumentiert und kodiert werden, z.B. Operationen.
Prozedur.OPSProzedurKodiert	Kodierung der durchgeführten Prozedur mittels OPS.
Prozedur.OPSProzedurKodiert.VollstaendigerProzedurenkode	Der vollständige Prozedurenkode: Tripel aus OPS-Kode, Kodesystem (inkl. Version!) und Katalogtext.
Prozedur.OPSProzedurKodiert.Seitenlokalisation	Seitenlokalisation für die durchgeführte Prozedur gemäß DIMDI
Prozedur.SNOMEDProzedurKodiert	Kodierung der durchgeführten Prozedur mittels SNOMED CT.
Prozedur.SNOMEDProzedurKodiert.VollstaendigerProzedurenkode	Der vollständige Prozedurenkode: Tripel aus SNOMED-CT-Kode, Kodesystem (Version optional) und Katalogtext.
Prozedur.Koerperstelle	Körperstelle der Prozedur mittels SNOMED CT inkl. Lateralität (R, L, B)
Prozedur.Durchfuehrungsabsicht	Intention mit der die Prozedur durchgeführt wird
Prozedur.Durchfuehrungsdatum	Durchführungsdatum der Prozedur
Prozedur.Dokumentationsdatum	Dokumentationsdatum der Prozedur
Prozedur.Freitextbeschreibung	Prozedur im Klartext