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1.Änderungen im Vergleich zur Version 1.0.0

1.1 Informationsmodell

Anpassung an die KBV-Basis-Profile in der Version 1.1.3

  • Die Elemente PatientIn, behandelnde Person, Einrichtung und Erstellungsdatum wurden aus der Version 1.1.3 der KBV-Basis-Profile abgeleitet und an das MIO Mutterpass angepasst

Erweiterung um folgende Elemente aufgrund des Beschlusses des G-BA vom 19.08.2021

  • Pertussis-Impfung
  • Bestimmung des fetalen Rhesus-Status

 Streichung folgender Elemente aufgrund des Beschlusses des G-BA vom 19.08.2021

  • Nitrit, Blut und Sediment, ggfs. bakteriologische Befunde beim Gravidogramm
  • Sediment unauffällig bei der zweiten Untersuchung nach Entbindung

Inhaltliche Anpassung folgender Elemente

  • In den Abschnitten Geburt, Wochenbett und zweite Untersuchung nach Entbindung jeweils unter 'Angaben zum Kind' → Das String-Element 'Nummer' wurde durch eine pid ersetzt

Strukturelle Anpassung folgender Elemente

  • Blutgruppe des Kindes beim Wochenbett
  • Stationäre Behandlung → Zeitraum

Redaktionelle Anpassung ohne inhaltliche Änderung folgender Elemente:

  • Blutgruppenzugehörigkeit → Rhesus-System (Beschreibungstext)
  • Schreibweise des Elements 'Cardiotokografie'
  • Zweite Untersuchung nach Entbindung (Beschreibungstext)
  • Laboruntersuchung, Ergebnis maskiert (statt 'Code Laboruntersuchung' nun 'Laboruntersuchung (LSR)')   

Anpassung der Kardinalitäten

  • PatientIn, Stempelinformationen des Arztes/der Klinik/der mitbetreuenden Hebamme, Stempelinformationen des Laborsztes/der Laborärztin und des Laboratoriums, Eintragende Person und Eintragende Einrichtung → Anpassung an die Kardinalitäten dr KBV-Basis-Profile in der Version 1.1.3
  • Geburtsdatum der Patientin → die zweite Bedingung ist nun "Nicht erlaubt"
  • Bei mehreren Elementen → statt "required" nun "optional"
  • Immunität anzunehmen → statt "conditional" nun "required"
  • I. Ultraschallscreening → nun 0..2 

Aufnahme von Operationalisierungshinweisen

  • Beim I. und III. Ultraschallscreening
  • Beim Katalog A


1.2 Codierung


Aktualisierung der Codes an aktuelles SNOMED CT® Release

Im Zuge des International Release 2021-07-31 wurden die Codes und Bezeichnungen (fully specified names) der Konzepte vollständig überarbeitet. Anpassung aller Codes und Bezeichnungen im Code-System.


Element im InformationsmodelVersion 1.0.0Version 1.1.0
Plazentalokalisation/-struktur normal169954003 Placenta normal O/E (finding)289279004 Placenta healthy (finding)
Erythrozyten im Blut, Anzahl pro Volumen363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=703062004,370132008=30766002,704318007=118550005Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Population of all erythrocytes in portion of fluid (body structure) , Scale type (attribute) = Quantitative (qualifier value) , Property type (attribute) = Number concentration (property) (qualifier value)363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=703062004,370132008=30766002,370130000=118550005Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Population of all erythrocytes in portion of fluid (body structure) , Scale type (attribute) = Quantitative (qualifier value) , Property (attribute) = Number concentration (property) (qualifier value)
Chlamydia trachomatis DNA aus einer Urinprobe mittels Nukleinsäure-amplifizierendem Test (NAT), Nachweis363787002:246093002=121181000,370134009=123029007,704327008=122575003,246501002=702675006,370132008=117363000,704318007=705057003,704319004=78014005Observable entity (observable entity) : Component (attribute) =  Deoxyribonucleic acid of Chlamydia trachomatis (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Urine specimen (specimen) , Technique (attribute) = Probe with target amplification technique (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Property type (attribute) = Presence (property) (qualifier value) , Inheres in (attribute) =  Urine (substance)363787002:246093002=121181000,370134009=123029007,704327008=122575003,246501002=702675006,370132008=117363000,370130000=705057003,704319004=78014005Observable entity (observable entity) : Component (attribute) =  Deoxyribonucleic acid of Chlamydia trachomatis (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Urine specimen (specimen) , Technique (attribute) = Probe with target amplification technique (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Property (attribute) = Presence (property) (qualifier value) , Inheres in (attribute) =  Urine (substance)
Hämoglobin im Blut, Mol pro Volumen363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=38082009,704318007=118556004,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Property type (attribute) = Substance concentration (property) (qualifier value) , Scale type (attribute) = Quantitative (qualifier value)363787002:704319004=87612001,704327008=119297000,370134009=123029007,246093002=38082009,370130000=118556004,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Property (attribute) = Substance concentration (property) (qualifier value) , Scale type (attribute) = Quantitative (qualifier value)
Hämoglobin im Blut, Masse pro Volumen363787002:704319004=87612001,704318007=118539007,704327008=119297000,370134009=123029007,246093002=38082009,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Property type (attribute) = Mass concentration (property) (qualifier value) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Scale type (attribute) = Quantitative (qualifier value)363787002:704319004=87612001,370130000=118539007,704327008=119297000,370134009=123029007,246093002=38082009,370132008=30766002Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Property (attribute) = Mass concentration (property) (qualifier value) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Component (attribute) = Hemoglobin (substance) , Scale type (attribute) = Quantitative (qualifier value)
HBs-Antigen im Serum, Nachweis363787002:370134009=123029007,370132008=117363000,704319004=50863008,246093002=22290004,704318007=705057003,704327008=119364003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Component (attribute) = Antigen of Hepatitis B virus surface protein (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:370134009=123029007,370132008=117363000,704319004=50863008,246093002=22290004,370130000=705057003,704327008=119364003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Component (attribute) = Antigen of Hepatitis B virus surface protein (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Titer363787002:246093002=120737006,704318007=118590008,370134009=123029007,370132008=30766002,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Property type (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370130000=118590008,370134009=123029007,370132008=30766002,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Property (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Konzentration IE pro Volumen363787002:246093002=120737006,370134009=123029007,370132008=30766002,704318007=118569000,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Property type (attribute) = Arbitrary concentration (property) (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370134009=123029007,370132008=30766002,370130000=118569000,704319004=50863008,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Quantitative (qualifier value) , Property (attribute) = Arbitrary concentration (property) (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Direct site (attribute) = Serum specimen (specimen)
Röteln Virus Antikörper im Serum, Nachweis363787002:246093002=120737006,370134009=123029007,370132008=117363000,704319004=50863008,704318007=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120737006,370134009=123029007,370132008=117363000,704319004=50863008,370130000=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Rubella virus antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Blood group antibody (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
Blutgruppen Antikörper-Suchtest im Serum/Plasma, Titer363787002:704318007=118590008,370134009=123029007,704327008=122592007,370132008=30766002,246093002=19830006,704319004=50863008Observable entity (observable entity) : Property type (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Scale type (attribute) = Quantitative (qualifier value) , Component (attribute) = Blood group antibody (substance) , Inheres in (attribute) = Blood group antibody (substance)363787002:370130000=118590008,370134009=123029007,704327008=122592007,370132008=30766002,246093002=19830006,704319004=50863008Observable entity (observable entity) : Property (attribute) = Dilution factor expressed as titer (property) (qualifier value) , Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Scale type (attribute) = Quantitative (qualifier value) , Component (attribute) = Blood group antibody (substance) , Inheres in (attribute) = Blood group antibody (substance)
Blutgruppen Antikörper-Suchtest im Serum/Plasma, Nachweis363787002:370134009=123029007,704327008=122592007,246093002=19830006,370132008=117363000,704319004=50863008,704318007=705057003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Component (attribute) = Blood group antibody (substance) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property type (attribute) = Presence (property) (qualifier value)363787002:370134009=123029007,704327008=122592007,246093002=19830006,370132008=117363000,704319004=50863008,370130000=705057003Observable entity (observable entity) : Time aspect (attribute) = Single point in time (qualifier value) , Direct site (attribute) = Acellular blood (serum or plasma) specimen (specimen) , Component (attribute) = Blood group antibody (substance) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property (attribute) = Presence (property) (qualifier value)
AB0-System363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=106202009Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in ABO blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,118598001=410656007,246093002=106202009Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in ABO blood group system (substance)
Rhesus-System363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,118598001=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)

Rhesus-System

363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,704318007=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property type (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)363787002:704319004=87612001,704327008=119297000,370134009=123029007,370132008=117362005,370130000=410656007,246093002=16951006Observable entity (observable entity) : Inheres in (attribute) = Blood (substance) , Direct site (attribute) = Blood specimen (specimen) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Nominal value (qualifier value) , Property (attribute) = Type (property) (qualifier value) , Component (attribute) = Antigen in Rh blood group system (substance)

Laboruntersuchung (LSR)

363787002:246093002=120723002,370134009=123029007,370132008=117363000,704319004=50863008,704318007=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Treponema pallidum antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property type (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)363787002:246093002=120723002,370134009=123029007,370132008=117363000,704319004=50863008,370130000=705057003,704327008=119364003Observable entity (observable entity) : Component (attribute) = Treponema pallidum antibody (substance) , Time aspect (attribute) = Single point in time (qualifier value) , Scale type (attribute) = Ordinal value (qualifier value) , Inheres in (attribute) = Plasma (substance) , Property (attribute) = Presence (property) (qualifier value) , Direct site (attribute) = Serum specimen (specimen)
pH-Wert (Nabelarterie)363787002:370134009=123029007,704319004=12499000,246093002=89177007,704318007=702700007,370132008=30766002,704327008=703430008Observable entity (observable entity):Time aspect (attribute)=Single point in time (qualifier value),Inheres in (attribute)=Cord blood (substance),Component (attribute)=Proton (substance),Property type (attribute)=Logarithmic substance concentration (property) (qualifier value),Scale type (attribute)=Quantitative (qualifier value),Direct site (attribute)=Arterial cord blood specimen (specimen)363787002:370134009=123029007,704319004=12499000,246093002=89177007,370130000=702700007,370132008=30766002,704327008=703430008Observable entity (observable entity):Time aspect (attribute)=Single point in time (qualifier value),Inheres in (attribute)=Cord blood (substance),Component (attribute)=Proton (substance),Property (attribute)=Logarithmic substance concentration (property) (qualifier value),Scale type (attribute)=Quantitative (qualifier value),Direct site (attribute)=Arterial cord blood specimen (specimen)

Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)

365638007Finding of Rh blood group (finding)365638007 + 160499008Finding of Rh blood group (finding) + Child of (finding)

Vaginale Untersuchung

275963006On examination - vaginal examination (finding)113023007Examination of vagina (procedure)
vag. Operation

129125009:{363589002=236974004,408730004=398166005}

Procedure with explicit context (situation):{Associated procedure (attribute)=Instrumental delivery (procedure),Procedure context (attribute)=Performed (qualifier value)}236974004Instrumental delivery (procedure)
Sektio

200144004

Deliveries by cesarean (finding)

11466000Cesarean section (procedure)
Spontangeburt

169961004

Normal birth (finding)

177184002Normal delivery procedure (procedure)

Kind verlegt am 243796009:{363589002=37729005,408732007=67822003}

Situation with explicit context (situation) : { Associated procedure (attribute) = Patient transfer, in-hospital (procedure) , Subject relationship context (attribute) = Child (person) }

107724000Patient transfer (procedure)

Herzaktion



277766008

Awareness of heart beat (finding)249045009Fetal heart sounds present (finding)
0h (Bombay)115733006Blood group O>h< Bombay Indian variant (finding)115731008Blood group O>h< Bombay (finding)
U3 durchgeführt713020001Child into care medical examination done (situation)444084004Child examination with explicit context (situation)
Stationäre Behandlung während der Schwangerschaft5491000179105Medical record summary (record artifact)422735006Summary clinical document (record artifact)
Thorax - Auffällige Herz/Thorax-Relation (Blickdiagnose)441920005Radiographic shadow of heart abnormal (finding)249042007:47429007=65476007Fetal heart finding (finding) : Associated with (attribute) = Abnormal size (finding)

Blutgruppe und Untergruppen (nur bei RH neg.- Mutter; kein Ausweis!)

365638007+160499008Finding of Rh blood group (finding) + Child of (finding)365638007+118188004Finding of Rh blood group (finding) + Finding of neonate (finding)

Angaben zum Kind

118188004Finding of neonate (finding)

133906008 : 363702006 = 118188004

Postpartum care (regime/therapy) : Has focus (attribute)| = Finding of neonate (finding) 

AU (Abdomen/Thorax-Umfang)396552003:704321009=268445003Abdominal circumference (observable entity) : Characterizes (attribute) = Ultrasound scan - obstetric (procedure)1156896009Thoracoabdominal circumference of fetus (observable entity)
FOD (Fronto-okzipitaler Durchmesser)304602002:704327008=3332001

Antenatal ultrasound finding (observable entity) : Direct site (attribute) = Occipitofrontal diameter of head (body structure)

1156893001Occipitofrontal diameter of fetal head (observable entity)
FS (Fruchtsackdurchmesser)248326004:704325000=70847004Body measure (observable entity) : Relative to (attribute) = Structure of amnion (body structure)1156895008Diameter of amniotic sac (observable entity)
Embryo darstellbar404684003:{418775008=446522006,363698007=609524001,363713009=52101004}Clinical finding (finding):{Finding method (attribute)=Ultrasonography in first trimester (procedure)|,Finding site (attribute)=Entire embryo proper (body structure),Has interpretation (attribute)=Present (qualifier value)}1157306001Embryo present in utero (finding)
Gynäkologischer Befund normal404684003:{363714003=83607001,363713009=17621005}Clinical finding (finding):{Interprets (attribute)=Gynecologic examination (procedure),Has interpretation (attribute)=Normal (qualifier value)}1157297002Gynecologic examination normal (finding)
Diagnosetest auffällig nein

166926006

Glucose tolerance test normal (finding)

1156100006Pregnancy with normal glucose tolerance test (finding)
Beratung über ausreichende Jodzufuhr während der Stillzeit erfolgt409066002:363702006=438901000124107Education, guidance and counseling (procedure) : Has focus (attribute) = Iodine supplement therapy (regime/therapy)1157300007Education about iodine supplement therapy (procedure)
Krebsfrüherkennungsuntersuchung409066002:363702006=15886004Education, guidance and counseling (procedure): Has focus (attribute) = Screening for cancer (procedure)1156103008Education about screening for malignant neoplasm (procedure)
Schwangerschaftswoche+Tage57036006Fetal gestational age (observable entity)1156738004Fetal gestational age in weeks and days (observable entity)
Schwangerschaftswoche+Tage (korrigiert)57036006:246501002=278395004Fetal gestational age (observable entity):Technique (attribute)= Imaging technique (qualifier value)1157308000Corrected fetal gestational age in weeks and days (observable entity)
Rumpf - Darstellbarkeit des Magens im linken Oberbauch302292003:363714003=(364146002:704327008=86367003)Finding of trunk structure (finding) : Interprets (attribute) = ( Stomach observable (observable entity) : Direct site (attribute) = Structure of left upper quadrant of abdomen (body structure) )1157188005Stomach present in left upper quadrant of abdomen (finding)
Kopf Darstellbarkeit des Kleinhirns406122000+106112009+106111002:{363698007=113305005}

Head finding (finding) + Fetal finding (finding) + Clinical sign related to pregnancy (finding) : { Finding site (attribute) = Cerebellar structure (body structure) }

1157174006Cerebellum present (finding)
(21) Komplikationen bei vorausgegangenen Entbindungen417662000:{408731000=410513005,408729009=410515003,246090004=199745000,408732007=410604004}History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value), Finding context (attribute) = Known present (qualifier value),Associated finding (attribute) = Complication occurring during labor and delivery (disorder), Subject relationship context (attribute) = Subject of record (person)}1156096005History of complication occurring during labor and delivery (situation)
(22) Komplikationen post partum417662000:{408731000=410513005,408729009=410515003,246090004=80113008,408732007=410604004}History of clinical finding in subject (situation) : { Temporal context (attribute) = In the past (qualifier value), Finding context (attribute) = Known present (qualifier value), Associated finding (attribute) = Complication of the puerperium (disorder), Subject relationship context (attribute) = Subject of record (person)}1156097001History of complication of puerperium (situation)
(8) Rhesus-Inkompatibilität (bei vorangegangenen Schwangerschaften)312850006:246090004=44795003History of disorder (situation):Associated finding (attribute)=Rhesus isoimmunization affecting pregnancy (disorder)1156098006History of Rhesus isoimmunization affecting pregnancy (situation)
Rumpf - Darstellbarkeit der Harnblase

441687008:{363713009=17621005,363714003=169251004}

Imaging of genitourinary system abnormal (finding):{Has interpretation (attribute)=Normal (qualifier value),Interprets (attribute)=Ultrasound scan of bladder (procedure)}

1157173000Bladder present (finding)
Perzentil363787002:370130000=118583003Observable entity (observable entity) : Property (attribute) = Percentile (property) (qualifier value)1157309008Percentile of fetal growth (observable entity)
(24) Zustand nach anderen Uterusoperationen416940007:363589002=79876008Past history of procedure (situation): Associated procedure (attribute) = Operation on uterus (procedure)1156095009History of operation on uterus (situation)
Schwangerschaft festgestellt am/in der74036000:370130000=410672004Pregnancy detection examination (procedure) : Property (attribute) = Date property (qualifier value)|1156894007Date of pregnancy detection (observable entity)
Thorax - Darstellbarkeit des Vier-Kammer-Blicks

169221005:363698007=43487005

Ultrasound obstetric scan normal (finding):Finding site (attribute)=All chambers of the heart (body structure)1157164008All chambers of heart present (finding)
Zum HIV-Antikörpertest409066002:363702006=165813002

Education, guidance and counseling (procedure): Has focus (attribute) = Human immunodeficiency virus antibody test (procedure)

1156102003Education about screening for human immunodeficiency virus (procedure)
Kontrollbedürftig129125009:408730004=410525008Procedure with explicit context (situation) : Procedure context (attribute) = Needed (qualifier value)

1157303009

Requires follow-up (finding)
Thorax - Persistierende Arrythmie im Untersuchungszeitraum

249042007:246090004=(698247007:371881003=243788004)

Fetal heart finding (finding) : Associated finding (attribute) = Cardiac arrhythmia (disorder) : During (attribute) = Child examination (procedure) )289444003:371881003=243788004Irregular fetal heart rhythm (finding) : During (attribute) = Child examination (procedure)

Aufnahme der Codes für folgende Elemente

  • Pertussis-Impfung
CodeBezeichnung im Code-SystemCode-System
132751000119107Diphtheria, tetanus and acellular pertussis vaccination given (situation)SNOMED Clinical Terms
  • Bestimmung des fetalen RhD-Status
CodeBezeichnung im Code-SystemCode-System
365638007+106112009Finding of Rh blood group (finding) + Fetal finding (finding)

SNOMED Clinical Terms

  • Angaben zur Mutter
CodeBezeichnung im Code-SystemCode-System
133906008Postpartum care (regime/therapy)SNOMED Clinical Terms

Aufnahme des LOINC® Codes als Mapping zu dem dazugehörigen gemappten SNOMED CT® Codes

  • Körpergewicht 
CodeBezeichnung im Code-SystemCode-System
29463-7Body weightLOINC®


Anpassung des Codes beim Element 'Wochenbett'

  • Code bei dem oberen Element wurde entfernt und auf das Element 'Angaben zur Mutter' verschoben


1.3 Technische Spezifikation

Anpassung der Version auf 1.1.0

  • Bei allen Profilen, Extensions, CodeSystemen, ValueSets, ConceptMaps und Beispieldateien

Aktualisierung der Version von SNOMED CT® und LOINC®

Anpassung spezifischer Codes

  • Entsprechend den in Abschnitt 1.2 erwähnten Aktualisierungen

Ergänzung folgender Profile

  • Ergänzung von KBV_PR_MIO_MR_Observation_Blood_Group_Serology_Fetus aufgrund des Beschlusses des G-BA vom 19.08.2021
  • Ergänzung von KBV_PR_MIO_MR_Observation_Child_Position_At_Birth, um die Position des Kindes bei der Geburt mit entsprechendem ValueSet darstellen zu können und als Differenzierung zum Profil KBV_PR_MIO_MR_Observation_Child_Position

Anpassung einzelner Profile:

  • Aufteilung von KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth in KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth_Child und KBV_PR_MIO_MR_ClinicalImpression_First_Examination_After_Childbirth_Mother
  • Aufteilung von KBV_PR_MIO_MR_Observation_Examination in KBV_PR_MIO_MR_Observation_Examination und KBV_PR_MIO_MR_Observation_Examination_Masked
  • Ergänzung der ConceptMap an KBV_PR_MIO_MR_ClinicalImpression_Pregnancy_Examination_Discharge_Summary.finding
  • KBV_PR_MIO_MR_Observation_Para.value[x] und KBV_PR_MIO_MR_Observation_Gravida.value[x] → valueInteger statt valueQuantity
  • Ergänzung von MustSupports in KBV_PR_MIO_MR_DiagnosticReport_Ultrasound_II und KBV_PR_MIO_MR_DiagnosticReport_Ultrasound_III
  • KBV_PR_MIO_MR_Observation_Previous_Pregnancy: Constraint zur Begrenzung der Länge des Date auf 4 Stellen
  • KBV_PR_MIO_MR_Procedure_Counselling → Ergänzung des fixed Value des Status
  • KBV_PR_MIO_MR_Observation_Baseline_Weight_Mother → Ergänzung des fixed Value des Codes und Löschung des ValueSets
  • KBV_PR_MIO_MR_Patient_Child, KBV_PR_MIO_MR_Practitioner und KBV_PR_MIO_MR_Composition → Ergänzung der Profil-Definition
  • KBV_PR_MIO_MR_Patient_Child: Als Identifier wird für das Kind nicht mehr die Nummer-Extension am Identifier verwendet sondern die pid, die in Form einer UUID vorliegen muss
  • KBV_PR_MIO_MR_Observation_Weight_Child → Ergänzung der Version in meta.profile
  • Anpassung der Referenzen in Sections der Composition → viele Observations sind nicht mehr direkt in der Composition sondern über die dort referenzierten DiagnosticReports und ClinicalImpressions referenziert 
  • KBV_PR_MIO_MR_Observation_Cardiotocography.code.coding.display.extension → Anpassung des fixedValue 
  • Da sich KBV_PR_MIO_MR_ClinicalImpression_Birth_Examination_Child_Information auf das geborene Kind bezieht, referenziert es jetzt nicht mehr die Mutter sondern das Kind als subject.

Anpassung folgender ValueSets, ConceptMaps, CodeSystems:

  • Ergänzung der Pertussis_Impfung in KBV_VS_MIO_MR_Immunization_Status, KBV_CM_MIO_MR_Immunization_Status_German und KBV_CS_MIO_MR_Immunization_Status_German

Anpassung an die KBV-Basis-Profile in der Version 1.1.3

  • Die Änderungshistorie der KBV-Basis-Profile kann unter V1.1.3 eingesehen werden

Ergänzung von Leerzeichen beim Hinweistext