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{
"resourceType": "StructureDefinition",
"id": "mii-pr-icu-score-cam-icu",
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score-cam-icu",
"version": "2026.0.0",
"name": "MII_PR_ICU_Score_CAM_ICU",
"title": "MII PR ICU Score CAM-ICU",
"status": "draft",
"publisher": "Medizininformatik Initiative",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "https://www.medizininformatik-initiative.de"
}
]
}
],
"description": "Confusion Assessment Method for the ICU (CAM-ICU) for delirium assessment. A two-step process: first assess arousal using RASS (Feature 1), then evaluate four features if RASS ≥ -3. Delirium is present if Features 1 and 2 are present, plus either Feature 3 or 4. The result is a binary outcome: positive (delirium present) or negative (delirium absent).",
"fhirVersion": "4.0.1",
"kind": "resource",
"abstract": false,
"type": "Observation",
"baseDefinition": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "Observation.code.coding",
"path": "Observation.code.coding",
"min": 1
},
{
"id": "Observation.code.coding:sct",
"path": "Observation.code.coding",
"sliceName": "sct",
"patternCoding": {
"code": "450740000",
"system": "http://snomed.info/sct",
"display": "Confusion Assessment Method for the intensive care unit score"
}
},
{
"id": "Observation.code.coding:loinc",
"path": "Observation.code.coding",
"sliceName": "loinc",
"min": 1,
"patternCoding": {
"code": "99844-5",
"system": "http://loinc.org",
"display": "Confusion Assessment Method for the ICU"
}
},
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"path": "Observation.value[x]",
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"binding": {
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"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/cam-icu-result"
}
},
{
"id": "Observation.interpretation",
"path": "Observation.interpretation",
"short": "Delirium status",
"binding": {
"strength": "extensible",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/delirium-interpretation"
}
},
{
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"path": "Observation.component",
"slicing": {
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"rules": "open"
},
"max": "4"
},
{
"id": "Observation.component:feature1-acute-change",
"path": "Observation.component",
"sliceName": "feature1-acute-change",
"short": "Acute change or fluctuating mental status",
"definition": "Is there an acute change from mental status baseline? Or has the patient's mental status fluctuated during the past 24 hours?",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.component:feature1-acute-change.code.text",
"path": "Observation.component.code.text",
"patternString": "Acute change from mental status baseline or Fluctuation in mental status in past 24 hours [CAM.ICU]"
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{
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"min": 1,
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"type": [
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],
"binding": {
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"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/present-absent"
}
},
{
"id": "Observation.component:feature2-inattention",
"path": "Observation.component",
"sliceName": "feature2-inattention",
"short": "Inattention present",
"definition": "Does the patient have difficulty focusing attention (e.g., easily distracted, difficulty keeping track of conversation)?",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.component:feature2-inattention.code.text",
"path": "Observation.component.code.text",
"patternString": "Feature 2: Inattention"
},
{
"id": "Observation.component:feature2-inattention.value[x]",
"path": "Observation.component.value[x]",
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"path": "Observation.component.value[x]",
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"min": 1,
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}
},
{
"id": "Observation.component:feature3-altered-loc",
"path": "Observation.component",
"sliceName": "feature3-altered-loc",
"short": "Current level of consciousness",
"definition": "Is the patient's level of consciousness anything other than alert (e.g., vigilant, lethargic, stupor, coma)?",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.component:feature3-altered-loc.code.text",
"path": "Observation.component.code.text",
"patternString": "Feature 3: Altered level of consciousness"
},
{
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"path": "Observation.component.value[x]",
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}
},
{
"id": "Observation.component:feature4-disorganized-thinking",
"path": "Observation.component",
"sliceName": "feature4-disorganized-thinking",
"short": "Disorganized thinking present",
"definition": "Is there evidence of disorganized or incoherent thinking (e.g., rambling, irrelevant conversation, unclear flow of ideas, illogical thinking)?",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.component:feature4-disorganized-thinking.code.text",
"path": "Observation.component.code.text",
"patternString": "Feature 4: Disorganized thinking"
},
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]
}
}
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