MII Implementierungsleitfaden Kerndatensatz Basis
2026.0.1 - Release Germany

MII Implementation Guide Core Dataset Base - Downloaded Version 2026.0.1 See the Directory of published versions

## Ressourcenprofil: MII PR Person Vitalstatus

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/core/modul-person/StructureDefinition/Vitalstatus | Version: 2026.0.1 | Highlight text changes?
Active Stand: 2026-06-09 | Maschinenlesbarer Name: MII_PR_Person_Vitalstatus

Vitalstatus einer Patientin oder eines Patienten.

Beispielhafte Anwendungsszenarien:

- Dokumentation des Vitalstatus (lebend/verstorben) einer PatientIn zu bestimmten Zeitpunkten
- Nachverfolgung des letzten bekannten Lebenszeitpunktes für PatientInnen in klinischen und Forschungskontexten
- Erfassung von Vitalstatus-Observationen bei jeder Krankenhausaufnahme und Entlassung
- Unterstützung von Mortalitätsanalysen und Überlebensstudien in Forschungsanwendungen
- Pflege der Vitalstatus-Historie durch mehrere Observation-Instanzen über die Zeit

### Profilspezifische Implementierungshinweise

Dieser Abschnitt enthält detaillierte Implementierungshinweise für das MII-Vitalstatus-Profil.

#### Anforderungen an Observation-Instanzen

Mehrere Observationen:

- Für jede Beobachtung/Angabe des Vitalstatus einer PatientIn MUSS eine neue Observation-Instanz erzeugt werden
- Alle Observation-Instanzen MÜSSEN `status='final'` haben
- Jede Instanz repräsentiert eine zeitpunktbezogene Aussage über den Vitalstatus der PatientIn

Häufigkeit der Dokumentation:

- Der Vitalstatus ("letzter bekannter Lebenszeitpunkt") SOLL mindestens bei jeder Aufnahme/Entlassung anlassbezogen als Observation erstellt werden
- Die Häufigkeit der Erhebung ist ansonsten nicht weiter geregelt und kann variieren
- Die Quelldaten sind oft nur schwer zu erschließen und erfordern möglicherweise manuelle Recherche (z.B. Kontaktaufnahme, öffentliche Informationen wie Todesanzeigen)

##### Best Practice - Datenquellen für Vitalstatus

Administrative Entlassung: Die administrative Entlassung der PatientIn aufgrund des Todes SOLL dokumentiert werden (siehe Modul Fall - Entlassungsgrund) und KANN als nützliche Datenquelle für den Vitalstatus dienen.

Integration: Systeme SOLLEN Workflows etablieren, um automatisch Vitalstatus-Observationen zu erstellen, wenn der Entlassungsgrund auf Tod hinweist, um Konsistenz zwischen administrativer und klinischer Dokumentation zu gewährleisten.

Manuelle Recherche: In Fällen, in denen der Vitalstatus unklar ist, kann manuelle Recherche notwendig sein (Kontaktversuche, öffentliche Aufzeichnungen). Dokumentieren Sie die Informationsquelle angemessen in zugehörigen Metadaten (Provenance-Ressource).

#### Verpflichtende Elemente

Feste Werte:

- `Observation.category`: Fester Wert `survey` MUSS vorhanden sein; weitere Codings sind OPTIONAL
- `Observation.code`: Fester LOINC-Code `67162-8` MUSS vorhanden sein; weitere Codings sind OPTIONAL

Patientenbezug:

- `Observation.subject`: Referenz auf Patient MUSS gegeben sein
- Der Vitalstatus ist inhärent patientenspezifisch und kann ohne diese Referenz nicht existieren

Effective DateTime:

- `Observation.effectiveDateTime`: VERPFLICHTEND genaue Angabe des letzten Lebendzeitpunktes
  - KANN partielle Datumsangaben enthalten (Jahr, Jahr-Monat), wenn das genaue Datum unbekannt ist
  - Enthält nicht den Todeszeitpunkt (siehe `Patient.deceased[x]` für die Dokumentation des Todes)
  - Repräsentiert den Zeitpunkt, zu dem die PatientIn bekanntermaßen im dokumentierten Vitalstatus war

##### Best Practice - effectiveDateTime vs. Patient.deceased[x]

Unterscheidung: `Observation.effectiveDateTime` repräsentiert den letzten bekannten Lebendzeitpunkt oder den Zeitpunkt der Vitalstatus-Feststellung, NICHT den Todeszeitpunkt.

Dokumentation des Todes: Verwenden Sie `Patient.deceased[x]` (vorzugsweise `deceasedDateTime`), um den tatsächlichen Todeszeitpunkt zu dokumentieren.

Beispielszenario:

- PatientIn lebend entlassen am 15.03.2024 → Vitalstatus-Observation mit `effectiveDateTime = 2024-03-15` und `valueCodeableConcept = "L" (lebend)`
- PatientIn verstorben bestätigt am 20.04.2024 → Aktualisierung `Patient.deceasedDateTime = 2024-04-20` und Erstellung einer neuen Vitalstatus-Observation mit `effectiveDateTime = 2024-04-20` und `valueCodeableConcept = "T" (tot)`

#### Wert-Dokumentation

`Observation.valueCodeableConcept`:

- Verwendet Codes aus dem MII Vitalstatus CodeSystem:
  - `L` = lebend
  - `T` = tot
  - `X` = unbekannt

Siehe Formal Views für das vollständige ValueSet-Binding.

Usages:

- Examples for this Profile: Observation/mii-exa-person-observation-vitalstatus-discharge and Observation/mii-exa-person-observation-vitalstatus
- CapabilityStatements using this Profile: MII CPS Person CapabilityStatement

You can also check for usages in the FHIR IG Statistics

### Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

- Schlüsselelemente-Tabelle
- Differential-Tabelle
- Snapshot-Tabelle
- Statistiken/Referenzen
- Alle

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
id | S Σ | 0..1 | id | Logical id of this artifact
meta | S Σ | 0..1 | Meta | Metadata about the resource
profile | S Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Status Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
text |  | 0..1 | string | Plain text representation of the concept
coding | S Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
version |  | 0..1 | string | Version of the system - if relevant
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
system | S Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code | S Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
code | S Σ | 1..1 | CodeableConcept | Code Binding: LOINCCodes (example): Codes identifying names of simple observations.
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S Σ | 1..1 | Coding | LOINC Code Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
version |  | 0..1 | string | Version of the system - if relevant
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
subject | S Σ | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S Σ | 1..1 | dateTime | Zeitpunkt
value[x] | S Σ C | 1..1 | CodeableConcept | Codierter Wert
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S Σ | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
note | S | 0..* | Annotation | Hinweis
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:survey | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Diese Struktur ist abgeleitet von Observation

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
id | S | 0..1 | id | Logical id of this artifact
meta | S | 0..1 | Meta | Metadata about the resource
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
status | S | 1..1 | code | Status Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following
coding | S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code | S | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
code | S | 1..1 | CodeableConcept | Code
Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S | 1..1 | Coding | LOINC Code Required Pattern: At least the following
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
subject | S | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S | 1..1 | dateTime | Zeitpunkt
value[x] | S | 1..1 | CodeableConcept | Codierter Wert
Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
note | S | 0..* | Annotation | Hinweis
bodySite |  | 0..0 |  | Observed body part
specimen |  | 0..0 |  | Specimen used for this observation
referenceRange |  | 0..0 |  | Provides guide for interpretation
component |  | 0..0 |  | Component results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
id | S Σ | 0..1 | id | Logical id of this artifact
meta | S Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | S Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for observation
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | Status Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Code Binding: LOINCCodes (example): Codes identifying names of simple observations.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S Σ | 1..1 | Coding | LOINC Code Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | S Σ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
effective[x] | S Σ | 1..1 | dateTime | Zeitpunkt
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation
value[x] | S Σ C | 1..1 | CodeableConcept | Codierter Wert
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S Σ | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note | S | 0..* | Annotation | Hinweis
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
Observation.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:survey | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.subject.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Observation.encounter.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG
Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.
Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std.
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.component.​dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.component.​interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Diese Struktur ist abgeleitet von Observation

Summary

Mandatory: 13 elements
Must-Support: 25 elements
Fixed: 1 element
Prohibited: 4 elements

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Observation.category
- The element 1 is sliced based on the value of Observation.code.coding
- The element 1 is sliced based on the value of Observation.value[x].coding

Schlüsselelemente-Ansicht

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
id | S Σ | 0..1 | id | Logical id of this artifact
meta | S Σ | 0..1 | Meta | Metadata about the resource
profile | S Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
status | ?!S Σ | 1..1 | code | Status Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
text |  | 0..1 | string | Plain text representation of the concept
coding | S Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
version |  | 0..1 | string | Version of the system - if relevant
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
system | S Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code | S Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
code | S Σ | 1..1 | CodeableConcept | Code Binding: LOINCCodes (example): Codes identifying names of simple observations.
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S Σ | 1..1 | Coding | LOINC Code Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
version |  | 0..1 | string | Version of the system - if relevant
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
subject | S Σ | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S Σ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S Σ | 1..1 | dateTime | Zeitpunkt
value[x] | S Σ C | 1..1 | CodeableConcept | Codierter Wert
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S Σ | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
system | S Σ | 1..1 | uri | Identity of the terminology system
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
note | S | 0..* | Annotation | Hinweis
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:survey | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Differential-Ansicht

Diese Struktur ist abgeleitet von Observation

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation |  | 0..* | Observation | Measurements and simple assertions
id | S | 0..1 | id | Logical id of this artifact
meta | S | 0..1 | Meta | Metadata about the resource
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
status | S | 1..1 | code | Status Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Required Pattern: At least the following
coding | S | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system | S | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
code | S | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
code | S | 1..1 | CodeableConcept | Code
Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S | 1..1 | Coding | LOINC Code Required Pattern: At least the following
system | S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code | S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
subject | S | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL
encounter | S | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
reference | S | 0..1 | string | Literal reference, Relative, internal or absolute URL
effective[x] | S | 1..1 | dateTime | Zeitpunkt
value[x] | S | 1..1 | CodeableConcept | Codierter Wert
Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
system | S | 1..1 | uri | Identity of the terminology system
code | S | 1..1 | code | Symbol in syntax defined by the system
note | S | 0..* | Annotation | Hinweis
bodySite |  | 0..0 |  | Observed body part
specimen |  | 0..0 |  | Specimen used for this observation
referenceRange |  | 0..0 |  | Provides guide for interpretation
component |  | 0..0 |  | Component results
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG

Snapshot-AnsichtView

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Observation | C | 0..* | Observation | Measurements and simple assertions Constraints: obs-6, obs-7
id | S Σ | 0..1 | id | Logical id of this artifact
meta | S Σ | 0..1 | Meta | Metadata about the resource
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
versionId | Σ | 0..1 | id | Version specific identifier
lastUpdated | Σ | 0..1 | instant | When the resource version last changed
source | Σ | 0..1 | uri | Identifies where the resource comes from
profile | S Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business Identifier for observation
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | Fulfills plan, proposal or order
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event
status | ?!S Σ | 1..1 | code | Status Binding: ObservationStatus (required): Codes providing the status of an observation. Fixed Value: final
Slices for category | S | 1..* | CodeableConcept | Kategorie Slice: Unordered, Open by pattern:$this Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
category:survey | S | 1..1 | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | S Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 0..1 | code | Symbol in syntax defined by the system Fixed Value: survey
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Code Binding: LOINCCodes (example): Codes identifying names of simple observations.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:loinc | S Σ | 1..1 | Coding | LOINC Code Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 67162-8
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
subject | S Σ | 1..1 | Reference(Patient | Group) | Who and/or what the observation is about
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
focus | Σ | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record
encounter | S Σ | 0..1 | Reference(Encounter) | Kontakt (Aufenthaltsbezug)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
reference | S Σ C | 0..1 | string | Literal reference, Relative, internal or absolute URL
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known
display | Σ | 0..1 | string | Text alternative for the resource
effective[x] | S Σ | 1..1 | dateTime | Zeitpunkt
issued | Σ | 0..1 | instant | Date/Time this version was made available
performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam | Patient | RelatedPerson) | Who is responsible for the observation
value[x] | S Σ C | 1..1 | CodeableConcept | Codierter Wert
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding | S Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:Vitalstatus | S Σ | 1..1 | Coding | Vitalstatus Binding: MII VS Person Vitalstatus (required)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
system | S Σ | 1..1 | uri | Identity of the terminology system
version | Σ | 0..1 | string | Version of the system - if relevant
code | S Σ | 1..1 | code | Symbol in syntax defined by the system
display | Σ | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation |  | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note | S | 0..* | Annotation | Hinweis
method |  | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations.
device |  | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Observation.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std.
Observation.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std.
Observation.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Observation.status | Base | required | ObservationStatus | 📍4.0.1 | FHIR Std.
Observation.category | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.category:survey | Base | preferred | Observation Category Codes | 📍4.0.1 | FHIR Std.
Observation.code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.subject.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Observation.encounter.​type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std.
Observation.value[x].​coding:Vitalstatus | Base | required | MII VS Person Vitalstatus | 📦2026.0.1 | This IG
Observation.dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.
Observation.method | Base | example | Observation Methods | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​type | Base | preferred | Observation Reference Range Meaning Codes | 📍4.0.1 | FHIR Std.
Observation.referenceRange.​appliesTo | Base | example | Observation Reference Range Applies To Codes | 📍4.0.1 | FHIR Std.
Observation.component.​code | Base | example | LOINC Codes | 📍4.0.1 | FHIR Std.
Observation.component.​dataAbsentReason | Base | extensible | DataAbsentReason | 📍4.0.1 | FHIR Std.
Observation.component.​interpretation | Base | extensible | Observation Interpretation Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | Observation | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | Observation | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | Observation | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | Observation | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`
obs-6 | error | Observation | dataAbsentReason SHALL only be present if Observation.value[x] is not present | `dataAbsentReason.empty() or value.empty()`
obs-7 | error | Observation | If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present | `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()`

Diese Struktur ist abgeleitet von Observation

Summary

Mandatory: 13 elements
Must-Support: 25 elements
Fixed: 1 element
Prohibited: 4 elements

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Observation.category
- The element 1 is sliced based on the value of Observation.code.coding
- The element 1 is sliced based on the value of Observation.value[x].coding

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