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{
"resourceType": "StructureDefinition",
"id": "DGUV-OPER-PR-OPProzedur",
"url": "http://fhir.dguv.de/OPER/Procedure/DGUV-OPER-PR-OPProzedur",
"version": "1.0",
"name": "DGUV_OPER_PR_OPProzedur",
"title": "OPProzedur",
"status": "draft",
"publisher": "Deutsche Gesetzliche Unfallversicherung e.V. (DGUV)",
"description": "Dieses Profil bildet die OP-Prozedur inkl. OP-Indikation, Narkose, Schnitt- und Nahtzeit und OPBefundVerlauf ab.",
"fhirVersion": "4.0.1",
"kind": "resource",
"abstract": false,
"type": "Procedure",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/Procedure",
"derivation": "constraint",
"differential": {
"element": [
{
"id": "Procedure",
"path": "Procedure",
"short": "OPProzedur"
},
{
"id": "Procedure.id",
"path": "Procedure.id",
"mustSupport": true
},
{
"id": "Procedure.meta",
"path": "Procedure.meta",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.meta.profile",
"path": "Procedure.meta.profile",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "$this"
}
],
"rules": "open"
},
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.meta.profile:operProfile",
"path": "Procedure.meta.profile",
"sliceName": "operProfile",
"min": 1,
"max": "1",
"fixedCanonical": "http://fhir.dguv.de/OPER/Procedure/DGUV-OPER-PR-OPProzedur",
"mustSupport": true
},
{
"id": "Procedure.extension",
"path": "Procedure.extension",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose",
"path": "Procedure.extension",
"sliceName": "Narkose",
"short": "Narkoseform/-bezeichnung",
"definition": "Narkoseform/-bezeichnung",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Narkose"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.extension:Narkose.value[x]",
"path": "Procedure.extension.value[x]",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose.value[x].coding",
"path": "Procedure.extension.value[x].coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose.value[x].coding.system",
"path": "Procedure.extension.value[x].coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose.value[x].coding.code",
"path": "Procedure.extension.value[x].coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose.value[x].coding.display",
"path": "Procedure.extension.value[x].coding.display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Narkose.value[x].text",
"path": "Procedure.extension.value[x].text",
"mustSupport": true
},
{
"id": "Procedure.extension:Schnittzeit",
"path": "Procedure.extension",
"sliceName": "Schnittzeit",
"max": "1",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Schnittzeit"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.extension:Schnittzeit.value[x]",
"path": "Procedure.extension.value[x]",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:Nahtzeit",
"path": "Procedure.extension",
"sliceName": "Nahtzeit",
"max": "1",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Nahtzeit"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.extension:Nahtzeit.value[x]",
"path": "Procedure.extension.value[x]",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.extension:OPBefundVerlauf",
"path": "Procedure.extension",
"sliceName": "OPBefundVerlauf",
"min": 1,
"max": "1",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-OPBefundVerlauf"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.extension:OPBefundVerlauf.value[x]",
"path": "Procedure.extension.value[x]",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.status",
"path": "Procedure.status",
"fixedCode": "completed",
"mustSupport": true
},
{
"id": "Procedure.code",
"path": "Procedure.code",
"short": "Angabe der OPProzedur als OPS-/Snomed-Codes oder Freitext",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.coding",
"path": "Procedure.code.coding",
"slicing": {
"discriminator": [
{
"type": "value",
"path": "system"
}
],
"rules": "open"
},
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS",
"path": "Procedure.code.coding",
"sliceName": "OPS",
"short": "OPS-Code",
"definition": "Operationen- und Prozedurenschlüssel in der aktuellen Version",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.extension",
"path": "Procedure.code.coding.extension",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.extension:Seitenlokalisation",
"path": "Procedure.code.coding.extension",
"sliceName": "Seitenlokalisation",
"max": "1",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.de/StructureDefinition/seitenlokalisation"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.code.coding:OPS.extension:Seitenlokalisation.value[x]",
"path": "Procedure.code.coding.extension.value[x]",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.extension:Seitenlokalisation.value[x].system",
"path": "Procedure.code.coding.extension.value[x].system",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.extension:Seitenlokalisation.value[x].code",
"path": "Procedure.code.coding.extension.value[x].code",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.extension:Seitenlokalisation.value[x].display",
"path": "Procedure.code.coding.extension.value[x].display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.system",
"path": "Procedure.code.coding.system",
"min": 1,
"fixedUri": "http://fhir.de/CodeSystem/bfarm/ops",
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.code",
"path": "Procedure.code.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.coding:OPS.display",
"path": "Procedure.code.coding.display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.coding:SNOMED",
"path": "Procedure.code.coding",
"sliceName": "SNOMED",
"short": "Snomed-Code",
"mustSupport": true
},
{
"id": "Procedure.code.coding:SNOMED.system",
"path": "Procedure.code.coding.system",
"min": 1,
"patternUri": "http://snomed.info/sct",
"mustSupport": true
},
{
"id": "Procedure.code.coding:SNOMED.code",
"path": "Procedure.code.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.coding:SNOMED.display",
"path": "Procedure.code.coding.display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.code.text",
"path": "Procedure.code.text",
"short": "Angabe der OPProzedur als Freitext",
"mustSupport": true
},
{
"id": "Procedure.subject",
"path": "Procedure.subject",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://fhir.dguv.de/OPER/Patient/DGUV-OPER-PR-VersichertePerson"
]
}
],
"mustSupport": true
},
{
"id": "Procedure.subject.reference",
"path": "Procedure.subject.reference",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.encounter",
"path": "Procedure.encounter",
"short": "Angabe der Fallnummer",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.encounter.identifier",
"path": "Procedure.encounter.identifier",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.encounter.identifier.value",
"path": "Procedure.encounter.identifier.value",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.performed[x]",
"path": "Procedure.performed[x]",
"min": 1,
"type": [
{
"code": "dateTime"
}
],
"mustSupport": true
},
{
"id": "Procedure.reasonCode",
"path": "Procedure.reasonCode",
"short": "Indikation (Grund für Operation) als Freitext",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Procedure.reasonCode.text",
"path": "Procedure.reasonCode.text",
"short": "OP-Indikation als Freitext",
"definition": "Dort sollen im Freitext verkürzt die anlassgebenden Kriterien für die konkrete OP dargestellt werden, die sich aus Vorgeschichte, klinischem und bildgebenden Befund ergeben haben.",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.bodySite",
"path": "Procedure.bodySite",
"short": "Körperstelle",
"mustSupport": true
},
{
"id": "Procedure.bodySite.coding",
"path": "Procedure.bodySite.coding",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Procedure.bodySite.coding.system",
"path": "Procedure.bodySite.coding.system",
"min": 1,
"fixedUri": "http://snomed.info/sct",
"mustSupport": true
},
{
"id": "Procedure.bodySite.coding.code",
"path": "Procedure.bodySite.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.bodySite.coding.display",
"path": "Procedure.bodySite.coding.display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.followUp",
"path": "Procedure.followUp",
"short": "Freitextliche Hinweise des Operateurs zur Nachbehandlung",
"comment": "Dieses Attribut bildet im Zusammenhang mit dem stationären Operationsbericht die freitextlichen Hinweise des Operateurs zur Nachbehandlung ab (z. B. anschließender Belastungsbeginn und Belastungsaufbau).",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"id": "Procedure.followUp.text",
"path": "Procedure.followUp.text",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.focalDevice",
"path": "Procedure.focalDevice",
"short": "Referenz auf Implantat",
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated",
"path": "Procedure.focalDevice.manipulated",
"type": [
{
"code": "Reference",
"targetProfile": [
"http://fhir.dguv.de/OPER/Device/DGUV-OPER-PR-Implantat"
]
}
],
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated.extension",
"path": "Procedure.focalDevice.manipulated.extension",
"max": "1",
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated.extension:Seitenlokalisation",
"path": "Procedure.focalDevice.manipulated.extension",
"sliceName": "Seitenlokalisation",
"max": "1",
"type": [
{
"code": "Extension",
"profile": [
"http://fhir.dguv.de/OPER/Extension/DGUV-OPER-EX-Seitenlokalisation"
]
}
],
"mustSupport": true,
"isModifier": false
},
{
"id": "Procedure.focalDevice.manipulated.extension:Seitenlokalisation.value[x]",
"path": "Procedure.focalDevice.manipulated.extension.value[x]",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated.extension:Seitenlokalisation.value[x].code",
"path": "Procedure.focalDevice.manipulated.extension.value[x].code",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated.extension:Seitenlokalisation.value[x].display",
"path": "Procedure.focalDevice.manipulated.extension.value[x].display",
"min": 1,
"mustSupport": true
},
{
"id": "Procedure.focalDevice.manipulated.reference",
"path": "Procedure.focalDevice.manipulated.reference",
"min": 1,
"mustSupport": true
}
]
}
}
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