HiGHmed

HiGHmed - Infection Control - ImplementationGuide

Befund - DiagnosticReport


Bestehende Profile Kerndatensatz Medizininformatik-Initiative

Modul Labor

Durch den Kerndatensatz der Medizininformatik Initative wird bereits das Konzept des "Laborbefunds" im Modul Labor definiert. Diese Spezifikation wird im Rahmen dieses Moduls wiederverwendet.

Siehe Profil "MI-Initiative - Laborprofile - DiagnosticReport".

Canonical URL: https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/DiagnosticReportLab

Es ist zu beachten, dass alle weiteren Vorgaben und Pflichtfelder des Kerndatensatz Moduls einzuhalten sind. Weitere Informationen finden sich im Abschnitt des ImplementationGuides - Modul Labor.


Abbildung Mikrobiologischen Befund - HiGHmed Use Case Infection Control

Hinweis Under Construction!
ig_bilder_Warning Das Use-Case-übergreifende Erweiterungsmodul 'Mikrobiologischer Befund' des Kerndatensatzes der Medizininformatik-Initative befindet zur Zeit der Veröffentlichung dieses Profil noch im Aufbau. Anpassungen im Zuge einer Harmonisierung sind somit noch möglich. Weitere Infos siehe ArtDecor Modell Mikrobiologischer Befund

Beschreibung

Das vorliegende abgeleitete Profil beschreibt einen Befund (DiagnosticReport) im HiGHmed Projekt, Infection Control. Dies ist unabhängig von der Probenart, d.h. gilt sowohl für einen Mikrobilogie- / Virlogie- oder Serologiebefund.

NameCanonical
Profile_HiGHmed_InfectionControl_DiagnosticReportLabhttp://highmed.org/fhir/StructureDefinition/ic/DiagnosticReportLab

Differential

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
id0..1string
extensionI0..*Extension
useΣ ?!0..1codeBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
valueS Σ1..1string
periodΣ I0..1Period
assignerS Σ I1..1MII-Reference(Organization)
basedOnS I1..1MII-Reference(Profile - HiGHmed - Infection Control - ServiceRequest)
statusS Σ ?!1..1codeBinding
id0..1string
extensionI0..*Extension
loinc-labS Σ1..1CodingPattern
diagnostic-service-sectionsS Σ1..1CodingPattern
loinc-microbiology-studiesS Σ1..1CodingBinding
loinc-microbiology-specializationS Σ I0..1CodingBinding
textΣ0..1string
id0..1string
extensionI0..*Extension
loinc-labReportS Σ1..1CodingPattern
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group | Device | Location)
encounterS Σ I0..1Reference(Encounter)
effectiveDateTimedateTime
issuedS Σ1..1instant
id0..1string
extensionI0..*Extension
referenceS Σ I0..1string
typeΣ0..1uriBinding
identifierS Σ0..1Identifier
displayΣ0..1string
resultsInterpreterS Σ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
id0..1string
extensionI0..*Extension
referenceS Σ I0..1string
typeΣ0..1uriBinding
identifierS Σ0..1Identifier
displayΣ0..1string
resultS I1..*MII-Reference(Observation)
imagingStudyI0..*Reference(ImagingStudy)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
comment0..1string
conclusionS0..1string
conclusionCode0..*CodeableConcept
presentedFormI0..*Attachment


Mapping

Alle Elemente für das Konzept Diagnose des Use Case - Infection Control lassen sich durch das Profil wie folgt abbilden:

Logischer Datensatz FHIR Element
Mikrobiologischerbefund.BerichtID DiagnosticReport.identifier:befund
Mikrobiologischerbefund.Status DiagnosticReport.status
Mikrobiologischerbefund.Fall-Kennung DiagnosticReport.encounter
Mikrobiologischerbefund.Labortest-Bezeichnung DiagnosticReport.code
Mikrobiologischerbefund.Probendetails DiagnosticReport.specimen. Siehe Probendetails - Specimen
Mikrobiologischerbefund.Kultur DiagnosticReport.result. Siehe Kultur - Observation
Mikrobiologischerbefund.Empfängerstandort DiagnosticReport.resultsInterpreter. Siehe Standort - Organization
Mikrobiologischerbefund.DetailsderTestanforderung DiagnosticReport.basedOn. Siehe Details der Testanforderung - ServiceRequest

Constraints

Folgende Invarianten müssen bei der Implementierung des Profils beachtet werden:

keyseverityhumanexpression
dia-ic-highmed-1errorMicrobiology LOINC Spezialisierungen dürfen nur ausgewählt werden, falls der Report als Microbiology studies kodiert wurde%resource.category.where(coding.where(code = '18725-2' and system = 'http://loinc.org').exists()).exists()

Terminology Bindings

PathNameStrengthURL
DiagnosticReport.category.codingDiagnosticReportStudiesrequiredhttp://highmed.org/fhir/ValueSet/ic/DiagnosticReportStudies
DiagnosticReport.category.codingMicrobiologySpecializationDiagnosticReportrequiredhttp://highmed.org/fhir/ValueSet/ic/MicrobiologySpecializationDiagnosticReport

Snapshot

idS Σ0..1string
id0..1string
extensionI0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceS Σ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionI0..*Extension
modifierExtension?! I0..*Extension
id0..1string
extensionI0..*Extension
useΣ ?!0..1codeBinding
id0..1string
extensionI0..*Extension
id0..1string
extensionI0..*Extension
systemS Σ1..1uriFixed Value
versionΣ0..1string
codeS Σ1..1codeFixed Value
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
systemS Σ1..1uri
valueS Σ1..1string
periodΣ I0..1Period
assignerS Σ I1..1MII-Reference(Organization)
basedOnS I1..1MII-Reference(Profile - HiGHmed - Infection Control - ServiceRequest)
statusS Σ ?!1..1codeBinding
id0..1string
extensionI0..*Extension
loinc-labS Σ1..1CodingPattern
diagnostic-service-sectionsS Σ1..1CodingPattern
loinc-microbiology-studiesS Σ1..1CodingBinding
loinc-microbiology-specializationS Σ I0..1CodingBinding
textΣ0..1string
id0..1string
extensionI0..*Extension
loinc-labReportS Σ1..1CodingPattern
textΣ0..1string
subjectS Σ I1..1MII-Reference(Patient | Group | Device | Location)
encounterS Σ I0..1Reference(Encounter)
effectiveDateTimedateTime
issuedS Σ1..1instant
id0..1string
extensionI0..*Extension
referenceS Σ I0..1string
typeΣ0..1uriBinding
identifierS Σ0..1Identifier
displayΣ0..1string
resultsInterpreterS Σ I0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
id0..1string
extensionI0..*Extension
referenceS Σ I0..1string
typeΣ0..1uriBinding
identifierS Σ0..1Identifier
displayΣ0..1string
resultS I1..*MII-Reference(Observation)
imagingStudyI0..*Reference(ImagingStudy)
id0..1string
extensionI0..*Extension
modifierExtensionΣ ?! I0..*Extension
comment0..1string
conclusionS0..1string
conclusionCode0..*CodeableConcept
presentedFormI0..*Attachment


Beispiel Mikrobiologischer Befund

{
    "resourceType": "DiagnosticReport",
    "id": "ExampleHiGHmedInfectionControlDiagnosticReportVirlogieBefund",
    "meta": {
        "profile":  [
            "http://highmed.org/fhir/StructureDefinition/ic/DiagnosticReportLab"
        ]
    },
    "identifier":  [
        {
            "type": {
                "coding":  [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                        "code": "FILL"
                    }
                ]
            },
            "system": "http://example.org/fhir/sid/lab-identifiers",
            "value": "123456",
            "assigner": {
                "reference": "Organization/ExampleHiGHmedInfectionControlOrganization"
            }
        }
    ],
    "basedOn":  [
        {
            "reference": "SerivceRequest/ExampleHiGHmedInfectionControlServiceRequest"
        }
    ],
    "status": "final",
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://loinc.org",
                    "code": "26436-6",
                    "display": "Laboratory studies (set)"
                },
                {
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "code": "LAB"
                },
                {
                    "system": "http://loinc.org",
                    "code": "18725-2",
                    "display": "Microbiology studies (set)"
                },
                {
                    "system": "http://loinc.org",
                    "code": "92893-7",
                    "display": "Microbiology - viral studies"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://loinc.org",
                "code": "11502-2",
                "display": "Laboratory report"
            }
        ]
    },
    "subject": {
        "reference": "Patient/123"
    },
    "effectiveDateTime": "2021-05-16T08:49:21+02:00",
    "issued": "2021-05-16T08:49:21+02:00",
    "specimen":  [
        {
            "reference": "Specimen/ExampleHiGHmedInfectionControlSpecimen"
        }
    ],
    "result":  [
        {
            "reference": "Observation/ExampleHiGHmedInfectionControlObservationMolekulareDiagnostik"
        }
    ]
}

Beispiel Virologischer Befund

{
    "resourceType": "DiagnosticReport",
    "id": "ExampleHiGHmedInfectionControlDiagnosticReportVirlogieBefund",
    "meta": {
        "profile":  [
            "http://highmed.org/fhir/StructureDefinition/ic/DiagnosticReportLab"
        ]
    },
    "identifier":  [
        {
            "type": {
                "coding":  [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                        "code": "FILL"
                    }
                ]
            },
            "system": "http://example.org/fhir/sid/lab-identifiers",
            "value": "123456",
            "assigner": {
                "reference": "Organization/ExampleHiGHmedInfectionControlOrganization"
            }
        }
    ],
    "basedOn":  [
        {
            "reference": "SerivceRequest/ExampleHiGHmedInfectionControlServiceRequest"
        }
    ],
    "status": "final",
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://loinc.org",
                    "code": "26436-6",
                    "display": "Laboratory studies (set)"
                },
                {
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "code": "LAB"
                },
                {
                    "system": "http://loinc.org",
                    "code": "18725-2",
                    "display": "Microbiology studies (set)"
                },
                {
                    "system": "http://loinc.org",
                    "code": "92893-7",
                    "display": "Microbiology - viral studies"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://loinc.org",
                "code": "11502-2",
                "display": "Laboratory report"
            }
        ]
    },
    "subject": {
        "reference": "Patient/123"
    },
    "effectiveDateTime": "2021-05-16T08:49:21+02:00",
    "issued": "2021-05-16T08:49:21+02:00",
    "specimen":  [
        {
            "reference": "Specimen/ExampleHiGHmedInfectionControlSpecimen"
        }
    ],
    "result":  [
        {
            "reference": "Observation/ExampleHiGHmedInfectionControlObservationMolekulareDiagnostik"
        }
    ]
}

Beispiel Serologischer Befund

{
    "resourceType": "DiagnosticReport",
    "id": "ExampleHiGHmedInfectionControlDiagnosticReportSerologieBefund",
    "meta": {
        "profile":  [
            "http://highmed.org/fhir/StructureDefinition/ic/DiagnosticReportLab"
        ]
    },
    "identifier":  [
        {
            "type": {
                "coding":  [
                    {
                        "system": "http://terminology.hl7.org/CodeSystem/v2-0203",
                        "code": "FILL"
                    }
                ]
            },
            "system": "http://example.org/fhir/sid/lab-identifiers",
            "value": "123456",
            "assigner": {
                "reference": "Organization/ExampleHiGHmedInfectionControlOrganization"
            }
        }
    ],
    "basedOn": {
        "reference": "SerivceRequest/ExampleHiGHmedInfectionControlServiceRequest"
    },
    "status": "final",
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://loinc.org",
                    "code": "26436-6",
                    "display": "Laboratory studies (set)"
                },
                {
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
                    "code": "LAB"
                },
                {
                    "system": "http://loinc.org",
                    "code": "18727-8",
                    "display": "Serology studies (set)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "system": "http://loinc.org",
                "code": "11502-2",
                "display": "Laboratory report"
            }
        ]
    },
    "subject": {
        "reference": "Patient/123"
    },
    "effectiveDateTime": "2021-05-16T08:49:21+02:00",
    "issued": "2021-05-16T08:49:21+02:00",
    "specimen": {
        "reference": "Specimen/ExampleHiGHmedInfectionControlSpecimen"
    },
    "result": {
        "reference": "Observation/ExampleHiGHmedInfectionControlObservationSerologischeDiagnostik"
    }
}