CH RAD-Order (R4)
2.0.0-ballot - ballot Switzerland flag

This page is part of the CH RAD-Order (R4) (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Questionnaire

Auftrag*

  • linkId: order

Daum/Zeit der Auftragserteilung

  • linkId: order.authoredOn
  • Definition:: http://fhir.ch/ig/ch-orf/StructureDefinition-ch-orf-servicerequest#ServiceRequest.authoredOn

Auftragsnummer des Auftraggebers

Identifier Domain der Auftragsnummer des Auftraggebers

Auftragsnummer des Auftragsempfängers

Identifier Domain der Auftragsnummer des Auftragsempfängers

Identifier des Vorgängerdokuments

Dringender Benachrichtigungskontakt für dieses Dokument

Zu benachrichtigende Person

Titel

Name

Vorname

Telefon

E-Mail

Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument

Zu benachrichtigende Person

Titel

Name

Vorname

Telefon

E-Mail

Auftragspriorität

Empfänger

Empfangende Person

Titel

Name

Vorname

GLN

ZSR

Telefon

E-Mail

Empfangende Organisation

Name der Organisation

GLN

Strasse, Hausnummer, Postfach etc.

  • linkId: receiver.organization.streetAddressLine

PLZ

  • linkId: receiver.organization.postalCode

Ort

  • linkId: receiver.organization.city

Land

  • linkId: receiver.organization.country

Initiant dieser Anmeldung

Juristische Beziehung zum Patienten

Persönliche Beziehung zum Patienten?

Gesundheitsfachperson oder -organisation

Gesundheitsfachperson

Titel

Name

Vorname

Telefon

E-Mail

Gesundheitsorganisatiton

Name der Organisation

Strasse, Hausnummer, Postfach etc.

  • linkId: initiator.practitionerRole.organization.streetAddressLine

PLZ

  • linkId: initiator.practitionerRole.organization.postalCode

Ort

  • linkId: initiator.practitionerRole.organization.city

Land

  • linkId: initiator.practitionerRole.organization.country

Andere Person

Name

Vorname

Telefon

E-Mail

Strasse, Hausnummer, Postfach etc.

  • linkId: initiator.relatedPerson.streetAddressLine

PLZ

  • linkId: initiator.relatedPerson.postalCode

Ort

  • linkId: initiator.relatedPerson.city

Land

  • linkId: initiator.relatedPerson.country

Patient*

Name

Ledigname

Vorname

Lokale Patienten-ID

Lokale Patienten-ID Domain

Geburtsdatum

Geschlecht

Zivilstand

Telefon

E-Mail

Strasse, Hausnummer, Postfach etc.

  • linkId: patient.streetAddressLine

PLZ

  • linkId: patient.postalCode

Ort

  • linkId: patient.city

Land

  • linkId: patient.country

Korrespondenzsprache

Kontaktperson

Beziehung

Name

Vorname

Telefon

E-Mail

Hausarzt

Hausarzt Person

Titel

Name

Vorname

GLN

ZSR

Telefon

E-Mail

Hausarzt Organisation

Name der Organisation

GLN

Strasse, Hausnummer, Postfach etc.

  • linkId: familydoctor.organization.streetAddressLine

PLZ

  • linkId: familydoctor.organization.postalCode

Ort

  • linkId: familydoctor.organization.city

Land

  • linkId: familydoctor.organization.country

Patientenaufnahme

Voraussichtlich: Ambulant / Stationär / Notfall

Zimmerkategorie

Kostenträger

Begünstigter (Patient)

AHV-Nr. des Patienten

Krankenkasse (nach KVG)

Name der Versicherung

Kennnummer der Versichertenkarte

Unfallversicherung (nach UVG)

Name der Versicherung

Schadennummer

Zusatzversicherung (nach VVG)

Name der Versicherung

Kennnummer der Versichertenkarte

Invalidenversicherung (IV)

IV-Verfügungsnummer

Militärversicherung (MV)

MV-Versichertennummer

Selbstzahler

Patient selbst

Andere Person

  • linkId: coverage.self.patientRelatedPerson
  • Definition:: Coverage.payor
  • Enable When: todo

Andere Person

  • linkId: coverage.self.relatedPerson
  • Definition:: Coverage.payor
  • Enable When: todo

Name

Vorname

Telefon

E-Mail

Strasse, Hausnummer, Postfach etc.

  • linkId: coverage.self.relatedPerson.streetAddressLine

PLZ

  • linkId: coverage.self.relatedPerson.postalCode

Ort

  • linkId: coverage.self.relatedPerson.city

Land

  • linkId: coverage.self.relatedPerson.country

Anderer Kostenträger

Name des Kostenträgers

Beliebige ID

Bemerkung zur ID

Absender*

  • linkId: sender

Verantwortlicher*

Verantwortliche Person

Titel

Name

Vorname

GLN

ZSR

Telefon

E-Mail

Verantwortliche Organisation

Name der Organisation

GLN

Strasse, Hausnummer, Postfach etc.

  • linkId: sender.author.organization.streetAddressLine

PLZ

  • linkId: sender.author.organization.postalCode

Ort

  • linkId: sender.author.organization.city

Land

  • linkId: sender.author.organization.country

Erfasser

Erfassende Person

Titel

Name

Vorname

Telefon

E-Mail

Kopieempfänger (Kopie dieses Auftrags und aller daraus resultierenden Resultate)

Gesundheitsfachperson oder -organisation

Gesundheitsfachperson

Titel

Name

Vorname

Telefon

E-Mail

Gesundheitsorganisatiton

Name der Organisation

  • linkId: receiverCopy.practitionerRole.organization.name
  • Definition:: Organization.name

Strasse, Hausnummer, Postfach etc.

  • linkId: receiverCopy.practitionerRole.organization.streetAddressLine

PLZ

  • linkId: receiverCopy.practitionerRole.organization.postalCode

Ort

  • linkId: receiverCopy.practitionerRole.organization.city

Land

  • linkId: receiverCopy.practitionerRole.organization.country

Patient selbst

  • linkId: receiverCopy.patient
  • Definition:: Patient

Andere Person

Name

Vorname

Telefon

E-Mail

Strasse, Hausnummer, Postfach etc.

  • linkId: receiverCopy.relatedPerson.streetAddressLine

PLZ

  • linkId: receiverCopy.relatedPerson.postalCode

Ort

  • linkId: receiverCopy.relatedPerson.city

Land

  • linkId: receiverCopy.relatedPerson.country

Vorgängiger Aufenthalt in Spital / Heim

Von

Bis

Spital /Heim

Name der Organisation

Strasse, Hausnummer, Postfach etc.

  • linkId: antecedentEpisodeOfCare.organization.streetAddressLine

PLZ

  • linkId: antecedentEpisodeOfCare.organization.postalCode

Ort

  • linkId: antecedentEpisodeOfCare.organization.city

Land

  • linkId: antecedentEpisodeOfCare.organization.country

Ort und Zeit der Durchführung der angeforderten Leistung

Ort der Durchführung

Name*

Telefon

E-Mail

Strasse, Hausnummer, Postfach etc.

  • linkId: appointment.location.streetAddressLine

PLZ

  • linkId: appointment.location.postalCode

Ort

  • linkId: appointment.location.city

Land

  • linkId: appointment.location.country

Datum und Zeit, wann der Termin bevorzugt geplant werden soll

Von

Bis

Status*

Patienteninformation für diesen Termin

Einverständniserklärung

Ist der Patient über die Anmeldung informiert und explizit einverstanden?

Anmerkung

  • linkId: patient.consent.statement.note

  • linkId: instruction

Angeforderte Leistung*

  • linkId: requestedService

Leistung*

  • linkId: requestedService.service
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.category
  • Answers: Requested Service

Klinische Fragestellung

  • linkId: reason

Fragestellung

  • linkId: reason.question
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.reasonCode

Bildgebendes Verfahren

  • linkId: imagingService

Art

  • linkId: imagingService.type
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.code
  • Answers: Modality Type

Weitere Angaben zur Bildgebung

  • linkId: orderDetail

Region

  • linkId: orderDetail.imagingRegion
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequestServiceRequest.orderDetail:imagingRegion
  • Answers: Imaging Region

Fokus

  • linkId: orderDetail.imagingFocus
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.bodySite
  • Answers: Imaging Focus

Seitenangabe

  • linkId: orderDetail.laterality
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions.html#ServiceRequest.orderDetail:laterality
  • Answers: Laterality

Ansicht

  • linkId: orderDetail.viewType
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#orderDetail:viewType
  • Answers: View Type

Manöver

  • linkId: orderDetail.maneuverType
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#orderDetail:maneuverType
  • Answers: Maneuver Type

Handlungsanleitung

  • linkId: orderDetail.guidanceForAction
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#orderDetail:guidanceForAction
  • Enable When: todo
  • Answers: Guidance for Action

Gewünschter Radiologe für die Befundung / für die Intervention

  • linkId: desiredRadiologist
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#performer

Name

Vorname

  • linkId: diagnosis

Diagnosen und Befunde

  • linkId: diagnosisList

Hauptdiagnose

  • linkId: diagnosisList.primaryDiagnosis
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#reasonReference

Nebendiagnose

  • linkId: diagnosisList.secondaryDiagnosis
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.supportingInfo:diagnosis

Grösse (cm)

  • linkId: diagnosisList.bodyHeight
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitionServiceRequest.supportingInfo:bodyHeight

Gewicht (kg)

  • linkId: diagnosisList.bodyWeight
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#supportingInfo:#ServiceRequest.supportingInfo:bodyWeight

  • linkId: caveats

Caveats

  • linkId: caveatList
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.supportingInfo:caveats

Beinträchtigte Blutgerinnung*

  • linkId: caveatList.bloodCoagulation
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.category.coding.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

INR

  • linkId: caveatList.bloodCoagulation.INR
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.evidence.detail
  • Enable When: todo

Wert (INR)

  • linkId: caveatList.bloodCoagulation.INR.quantity
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-INR-observation-definitions#Observation.valueQuantity

Zeitpunkt der Bestimmung

  • linkId: caveatList.bloodCoagulation.INR.dateTime
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-INR-observation-definitions#Observation.effectiveDateTime

Thrombozyten

  • linkId: caveatList.bloodCoagulation.platelets
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.evidence.detail

Wert (10^9/L)

  • linkId: caveatList.bloodCoagulation.platelets.quantity
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-platelets-observation-definitions#Observation.valueQuantity

Zeitpunkt der Bestimmung

  • linkId: caveatList.bloodCoagulation.platelets.dateTime
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-platelets-observation-definitions#Observation.effectiveDateTime

Niereninsuffizienz*

  • linkId: caveatList.renalInsufficiency
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Creatinin-Clearance

  • linkId: caveatList.renalInsufficiency.creatinineClearance
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.evidence.detail

Wert (mL/min)

  • linkId: caveatList.renalInsufficiency.creatinineClearance.quantity
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-creatinineclearance-observation-definitions#Observation.valueQuantity

Zeitpunkt der Bestimmung

  • linkId: caveatList.renalInsufficiency.creatinineClearance.dateTime
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-creatinineclearance-observation-definitions#Observation.effectiveDateTime

Creatinin

  • linkId: caveatList.renalInsufficiency.creatinine
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.evidence.detail

Wert (µmol/L)

  • linkId: caveatList.renalInsufficiency.creatinine.quantity
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-creatinine-observation-definitions#Observation.valueQuantity

Zeitpunkt der Bestimmung

  • linkId: caveatList.renalInsufficiency.creatinine.dateTime
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-creatinine-observation-definitions#Observation.effectiveDateTime

Klaustrophobie*

  • linkId: caveatList.claustrophobia
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Körperpiercing*

  • linkId: caveatList.bodyPiercing
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Device (Herzschrittmacher, Herzklappenersatz, Insulinpumpe etc.)

  • linkId: caveatList.device
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#ch-rad-order-caveat-type
  • Answers: Caveat Device

Hyperthyreose*

  • linkId: caveatList.hyperthyroidism
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Diabetes mellitus*

  • linkId: caveatList.diabetes
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Schwangerschaft*

  • linkId: caveatList.gravida
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Kontrastmittelallergie*

  • linkId: caveatList.contrastMediaAllergy
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Relevante Medikamente*

  • linkId: caveatList.drugPrescription

Metformin*

  • linkId: caveatList.drugPrescription.metformin
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Betablocker*

  • linkId: caveatList.drugPrescription.betaBlocker
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-caveat-condition-definitions#Condition.code
  • Answers: Qualifier Value
  • Initial Values: Undetermined (qualifier value) (Details: SNOWMED CT code 373068000 = 'Undetermined (qualifier value)', stated as 'null')

Vorherige Untersuchungsresultate

  • linkId: previousResults

Datei

  • linkId: attachedFile
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-orf-documentreference-defintions#DocumentReference.content.attachedFile

Beschreibung

  • linkId: attachedFile.description
  • Definition:: http://fhir.ch/ig/ch-orf/StructureDefinition/ch-orf-documentreference-definitions#DocumentReference.description

DICOM Objekt

  • linkId: dicomObject

DICOM SOP Instance UID*

  • linkId: dicomObject.sopInstanceUid
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#ImagingStudy.series.instance.uid

DICOM SOP Class*

  • linkId: dicomObject.sopClass
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#ImagingStudy.series.instance.sopClass.value
  • Answers: https://dicom.nema.org/medical/dicom/current/output/chtml/part04/sect_B.5.html#table_B.5-1

DICOM Series Modality*

  • linkId: dicomObject.modality
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#.ImagingStudy.series.modality.coding
  • Answers: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html

DICOM Series Instance UID*

  • linkId: dicomObject.SeriesInstanceUid
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#ImagingStudy.series.uid

DICOM Study Instance UID*

  • linkId: dicomObject.studyInstanceUid
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#ImagingStudy.identifier

ACSN

  • linkId: dicomObject.acsn
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-imagingstudy-definitions#ImagingStudy.identifier

Bemerkungen

  • linkId: note

Kommentar

  • linkId: note.text
  • Definition:: http://fhir.ch/ig/ch-rad-order/StructureDefinition/ch-rad-order-servicerequest-definitions#ServiceRequest.note.text