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{
"resourceType": "StructureDefinition",
"id": "mii-pr-icu-score",
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score",
"version": "2026.0.0",
"name": "MII_PR_ICU_Score",
"title": "MII PR ICU Score",
"status": "draft",
"publisher": "Medizininformatik Initiative",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "https://www.medizininformatik-initiative.de"
}
]
}
],
"description": "Parent profile for ICU scoring systems. Scores are represented as Observations with the total score in value[x] and subscores as components. This profile defines common constraints for all ICU scores including sedation scores (RASS), pain scores (NRS, BPS), delirium assessments (CAM-ICU, ICDSC), and severity scores (SOFA, qSOFA).",
"fhirVersion": "4.0.1",
"kind": "resource",
"abstract": true,
"type": "Observation",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "Observation",
"path": "Observation",
"constraint": [
{
"key": "obs-10",
"human": "Either subject XOR encounter exists",
"source": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score",
"severity": "error",
"expression": "$this.encounter.exists() xor $this.subject.exists()"
},
{
"key": "vs-de-2",
"human": "If there is no component or hasMember element then either a value[x] or a data absent reason must be present",
"source": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score",
"severity": "error",
"expression": "(component.empty() and hasMember.empty()) implies (dataAbsentReason.exists() or value.exists())"
}
]
},
{
"id": "Observation.status",
"path": "Observation.status",
"short": "Status of the observation",
"comment": "Typically 'final' for completed scores, 'preliminary' for incomplete assessments",
"mustSupport": true
},
{
"id": "Observation.category",
"path": "Observation.category",
"slicing": {
"discriminator": [
{
"type": "pattern",
"path": "$this"
}
],
"rules": "open"
},
"min": 2,
"mustSupport": true
},
{
"id": "Observation.category:survey",
"path": "Observation.category",
"sliceName": "survey",
"short": "Survey category",
"min": 1,
"max": "1",
"patternCodeableConcept": {
"coding": [
{
"code": "survey",
"system": "http://terminology.hl7.org/CodeSystem/observation-category"
}
]
},
"mustSupport": true
},
{
"id": "Observation.category:survey.coding",
"path": "Observation.category.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.category:survey.coding.system",
"path": "Observation.category.coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.category:survey.coding.code",
"path": "Observation.category.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.category:assessment-scale",
"path": "Observation.category",
"sliceName": "assessment-scale",
"short": "Assessment scale category",
"min": 1,
"max": "1",
"patternCodeableConcept": {
"coding": [
{
"code": "273249006",
"system": "http://snomed.info/sct",
"display": "Assessment scales (assessment scale)"
}
]
},
"mustSupport": true
},
{
"id": "Observation.category:assessment-scale.coding",
"path": "Observation.category.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Observation.category:assessment-scale.coding.system",
"path": "Observation.category.coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.category:assessment-scale.coding.code",
"path": "Observation.category.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.code",
"path": "Observation.code",
"short": "Type of score",
"definition": "Identifies which score is being represented",
"constraint": [
{
"key": "obs-loinc-sct",
"human": "Es muss mindestens ein LOINC oder SnomedCT Code vorhanden sein",
"source": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/StructureDefinition/mii-pr-icu-score",
"severity": "error",
"expression": "coding.where(system='http://loinc.org').exists().not() implies coding.where(system='http://snomed.info/sct').exists()"
}
],
"mustSupport": true
},
{
"id": "Observation.code.coding",
"path": "Observation.code.coding",
"slicing": {
"discriminator": [
{
"type": "pattern",
"path": "$this"
}
],
"rules": "open"
},
"mustSupport": true
},
{
"id": "Observation.code.coding:sct",
"path": "Observation.code.coding",
"sliceName": "sct",
"short": "SNOMED CT code for the score",
"min": 0,
"max": "1",
"patternCoding": {
"system": "http://snomed.info/sct"
},
"mustSupport": true,
"binding": {
"strength": "extensible",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/score-snomed"
}
},
{
"id": "Observation.code.coding:sct.system",
"path": "Observation.code.coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.code.coding:sct.code",
"path": "Observation.code.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.code.coding:loinc",
"path": "Observation.code.coding",
"sliceName": "loinc",
"short": "LOINC code for the score",
"min": 0,
"max": "1",
"patternCoding": {
"system": "http://loinc.org"
},
"mustSupport": true,
"binding": {
"strength": "extensible",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-icu/ValueSet/score-loinc"
}
},
{
"id": "Observation.code.coding:loinc.system",
"path": "Observation.code.coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.code.coding:loinc.code",
"path": "Observation.code.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.subject",
"path": "Observation.subject",
"short": "Patient being assessed",
"min": 1,
"type": [
{
"code": "Reference",
"targetProfile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"mustSupport": true
},
{
"id": "Observation.encounter",
"path": "Observation.encounter",
"short": "Encounter during which score was assessed",
"definition": "The encounter context in which the score was determined",
"min": 1,
"mustSupport": true
},
{
"id": "Observation.effective[x]",
"path": "Observation.effective[x]",
"short": "Time of score assessment",
"definition": "The time or time period when the score was assessed",
"min": 1,
"type": [
{
"code": "dateTime"
}
],
"mustSupport": true
},
{
"id": "Observation.issued",
"path": "Observation.issued",
"short": "Date/Time this observation was made available",
"mustSupport": true
},
{
"id": "Observation.performer",
"path": "Observation.performer",
"short": "Who performed the score assessment",
"mustSupport": true
},
{
"id": "Observation.value[x]",
"path": "Observation.value[x]",
"short": "Total score value",
"definition": "The total score calculated. For numeric scores use integer or Quantity. For categorical results (e.g., positive/negative) use CodeableConcept.",
"comment": "Child profiles should constrain this further based on the specific score type",
"type": [
{
"code": "Quantity"
},
{
"code": "CodeableConcept"
},
{
"code": "integer"
}
],
"mustSupport": true
},
{
"id": "Observation.dataAbsentReason",
"path": "Observation.dataAbsentReason",
"short": "Why the score value is missing",
"mustSupport": true
},
{
"id": "Observation.interpretation",
"path": "Observation.interpretation",
"short": "Clinical interpretation of the score",
"definition": "Categorization of the score (e.g., mild, moderate, severe sedation for RASS)",
"mustSupport": true
},
{
"id": "Observation.note",
"path": "Observation.note",
"short": "Comments about the score",
"mustSupport": true
},
{
"id": "Observation.bodySite",
"path": "Observation.bodySite",
"max": "0"
},
{
"id": "Observation.specimen",
"path": "Observation.specimen",
"max": "0"
},
{
"id": "Observation.device",
"path": "Observation.device",
"short": "Device used for automated score calculation (if applicable)",
"mustSupport": true
},
{
"id": "Observation.referenceRange",
"path": "Observation.referenceRange",
"short": "Reference range for score interpretation",
"mustSupport": true
},
{
"id": "Observation.hasMember",
"path": "Observation.hasMember",
"short": "Related observations (e.g., individual assessment items)",
"mustSupport": true
},
{
"id": "Observation.derivedFrom",
"path": "Observation.derivedFrom",
"short": "Source observations used to calculate score",
"mustSupport": true
},
{
"id": "Observation.component",
"path": "Observation.component",
"short": "Subscore components",
"definition": "Individual components or subscores that contribute to the total score. Child profiles should define specific components.",
"mustSupport": true
},
{
"id": "Observation.component.code",
"path": "Observation.component.code",
"short": "Type of component/subscore",
"mustSupport": true
},
{
"id": "Observation.component.value[x]",
"path": "Observation.component.value[x]",
"short": "Subscore value",
"type": [
{
"code": "Quantity"
},
{
"code": "CodeableConcept"
},
{
"code": "integer"
}
],
"mustSupport": true
},
{
"id": "Observation.component.dataAbsentReason",
"path": "Observation.component.dataAbsentReason",
"mustSupport": true
},
{
"id": "Observation.component.interpretation",
"path": "Observation.component.interpretation",
"mustSupport": true
}
]
}
}
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