MII_IG_MolGen_1

Befundbericht - DiagnosticReport

Beschreibung

Dieses Profil beschreibt molekulargenetischen Befundbericht der Medizininformatik-Initiative.

Name	Canonical
MII_PR_MolGen_MolekulargenetischerBefundbericht	https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/molekulargenetischer-befundbericht

Das Profil ist abgeleitet vom Profil Genomics Report aus HL7 Genomics Reporting Implementation Guide.

Für den Use Case, dass die EBM Abrechnungsziffern in einem Befund angegeben werden,
wird die Supporting Information Extension in DiagnosticReport.extension mit Reference auf ChargeItem Ressource verwendet.
Ein passendes Profil für ChargeItem kann aus den deutschen FHIR Basisprofilen verwendet werden.

Diff

MII_PR_MolGen_MolekulargenetischerBefundbericht (DiagnosticReport)

GenomicReport

Element id

DiagnosticReport

Short description

A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports

Alternate names

Report, Test, Result, Results, Labs, Laboratory

Definition

The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.

Comments

This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.

Data type

GenomicReport

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: 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-3: 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-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
v2: ORU -> OBR
rim: Observation[classCode=OBS, moodCode=EVN]
MII-KDS: mide-dataelement-1371

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

string

Meta

There are no (further) constraints on this element

Element id

DiagnosticReport.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Meta

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

uri

There are no (further) constraints on this element

Element id

DiagnosticReport.implicitRules

Short description

A set of rules under which this content was created

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

uri

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

DiagnosticReport.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Data type

code

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

Narrative

There are no (further) constraints on this element

Element id

DiagnosticReport.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Narrative

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

Resource

There are no (further) constraints on this element

Element id

DiagnosticReport.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Resource

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

recommended-action

S C

0..*

Extension(Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme | MII_PR_MolGen_Medikationsempfehlung))

Element id

DiagnosticReport.extension:recommended-action

Short description

Empfohlene Maßnahme

Alternate names

extensions, user content

Definition

Referenz zu empfohlenen Folgemaßnahmen oder Medikationsempfehlungen

Comments

Data type

Extension(Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme | MII_PR_MolGen_Medikationsempfehlung))

Extension URL

https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/empfohlene-massnahme

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

genomic-risk-assessment

S C

0..*

Extension(Reference(RiskAssessment))

Element id

DiagnosticReport.extension:genomic-risk-assessment

Short description

Genomische Risikobewertung

Alternate names

extensions, user content

Definition

Referenz zu einer genomischen Risikobewertung

Comments

Data type

Extension(Reference(RiskAssessment))

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-risk-assessment

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coded-note

S C

0..*

Extension(CodedAnnotation)

Element id

DiagnosticReport.extension:coded-note

Short description

Kodierte Anmerkung

Alternate names

extensions, user content

Definition

Kodierte Anmerkungen zum genetischen Bericht

Requirements

Need to be able to provide free text additional information. Notes SHALL NOT contain information which can be captured in a structured way.

Comments

May include general statements about the report, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation. The CodedAnnotation data type, while not allowing for or intending to make the content computable, does allow the author to indicate the type of note. This does not replace the use of results or conclusion or conclusionCode. One important note is that Annotation is a FHIR data type, this is NOT about annotations in the genomic context.

Data type

Extension(CodedAnnotation)

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-report-note

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

supporting-info

S C

0..*

Extension(Reference(Resource))

Element id

DiagnosticReport.extension:supporting-info

Short description

Unterstützende Informationen

Alternate names

extensions, user content

Definition

Zusätzliche unterstützende Informationen wie Familienanamnese oder Abrechnungsdaten

Comments

Data type

Extension(Reference(Resource))

Extension URL

http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

genomic-study

S C

0..*

Extension(Reference(GenomicStudy))

Element id

DiagnosticReport.extension:genomic-study

Short description

Genomische Studie

Alternate names

extensions, user content

Definition

Referenz zur zugehörigen genomischen Studie

Comments

Data type

Extension(Reference(GenomicStudy))

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-study-reference

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

hla-genotyping-results-allele-database

0..1

Extension(CodeableConcept)

There are no (further) constraints on this element

Element id

DiagnosticReport.extension:hla-genotyping-results-allele-database

Short description

Allele Database

Alternate names

extensions, user content

Definition

Allele Database.

Comments

Data type

Extension(CodeableConcept)

Extension URL

http://hl7.org/fhir/StructureDefinition/hla-genotyping-results-allele-database

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

hla-genotyping-results-glstring

0..1

Extension(Complex)

There are no (further) constraints on this element

Element id

DiagnosticReport.extension:hla-genotyping-results-glstring

Short description

glstring

Alternate names

extensions, user content

Definition

glstring.

Comments

Data type

Extension(Complex)

Extension URL

http://hl7.org/fhir/StructureDefinition/hla-genotyping-results-glstring

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

workflow-relatedArtifact

S C

0..*

Extension(RelatedArtifact)

Element id

DiagnosticReport.extension:workflow-relatedArtifact

Short description

Verknüpfte Artefakte

Alternate names

extensions, user content

Definition

Verknüpfte Literatur oder andere Artefakte wie Zitationen

Comments

Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource.

Data type

Extension(RelatedArtifact)

Extension URL

http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

0..*

Identifier

There are no (further) constraints on this element

Element id

DiagnosticReport.identifier

Short description

Business identifier for report

Alternate names

ReportID, Filler ID, Placer ID

Definition

Identifiers assigned to this report by the performer or other systems.

Requirements

Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.

Comments

Usually assigned by the Information System of the diagnostic service provider (filler id).

Data type

Identifier

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
v2: OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
rim: id

basedOn

0..*

Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)

There are no (further) constraints on this element

Element id

DiagnosticReport.basedOn

Short description

What was requested

Alternate names

Request

Definition

Details concerning a service requested.

Requirements

This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

Comments

Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.

Data type

Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.basedOn
v2: ORC? OBR-2/3?
rim: outboundRelationship[typeCode=FLFS].target

status

S Σ ?!

1..1

codeBinding

Element id

DiagnosticReport.status

Short description

Status

Alternate names

Berichtstatus

Definition

Status des Befundberichts

Requirements

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

code

Binding

The status of the diagnostic report.

DiagnosticReportStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
v2: OBR-25 (not 1:1 mapping)
rim: statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
MII-KDS: mide-dataelement-1448

category

1..*

CodeableConcept

There are no (further) constraints on this element

Element id

DiagnosticReport.category

Short description

Service category

Alternate names

Department, Sub-department, Service, Discipline

Definition

A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.

Comments

Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.

Data type

CodeableConcept

Slicing

Unordered, Open, by coding(Value)

Slice based on the category code pattern

Binding

Codes for diagnostic service sections.

DiagnosticServiceSectionCodes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
w5: FiveWs.class
v2: OBR-24
rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code

Genetics

1..1

CodeableConcept

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics

Short description

Service category

Alternate names

Department, Sub-department, Service, Discipline

Definition

Comments

Data type

CodeableConcept

Binding

Codes for diagnostic service sections.

DiagnosticServiceSectionCodes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
w5: FiveWs.class
v2: OBR-24
rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

string

Mappings

rim: n/a

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

1..1

CodingPattern

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Data type

Coding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
  "code": "GE"
}

Mappings

rim: n/a
v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
rim: CV
orim: fhir:Coding rdfs:subClassOf dt:CDCoding
v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding

text

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

code

1..1

CodeableConceptBindingPattern

There are no (further) constraints on this element

Element id

DiagnosticReport.code

Short description

Name/Code for this diagnostic report

Alternate names

Type

Definition

A code or name that describes this diagnostic report.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Data type

CodeableConcept

Binding

Codes that describe Diagnostic Reports.

LOINCDiagnosticReportCodes (preferred)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "51969-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.what[x]
v2: OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
rim: code

subject

S Σ C

1..1

Reference(Group | Patient)

Element id

DiagnosticReport.subject

Short description

Patient

Alternate names

Patient

Definition

Der Patient auf den sich der Befundbericht bezieht

Requirements

SHALL know the subject context.

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Data type

Reference(Group | Patient)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.subject
w5: FiveWs.subject[x]
v2: PID-3 (no HL7 v2 mapping for Group or Device)
rim: participation[typeCode=SBJ]
w5: FiveWs.subject

encounter

S Σ C

0..1

Reference(Encounter)

Element id

DiagnosticReport.encounter

Short description

Kontakt

Alternate names

Context

Definition

Der Kontakt in dessen Rahmen der Bericht erstellt wurde

Requirements

Links the request to the Encounter context.

Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

Data type

Reference(Encounter)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.encounter
w5: FiveWs.context
v2: PV1-19
rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]

effective[x]

0..1

There are no (further) constraints on this element

Element id

DiagnosticReport.effective[x]

Short description

Clinically relevant time/time-period for report

Alternate names

Observation time, Effective Time, Occurrence

Definition

The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.

Requirements

Need to know where in the patient history to file/present this report.

Comments

If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
v2: OBR-7
rim: effectiveTime

effectiveDateTime

dateTime

There are no (further) constraints on this element

Data type

dateTime

issued

S Σ

0..1

instant

Element id

DiagnosticReport.issued

Short description

Freigabedatum

Alternate names

Date published, Date Issued, Date Verified, Datum des Berichtes

Definition

Datum und Uhrzeit der Freigabe des Berichts

Requirements

Clinicians need to be able to check the date that the report was released.

Comments

May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

Data type

instant

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.recorded
v2: OBR-22
rim: participation[typeCode=VRF or AUT].time
MII-KDS: mide-dataelement-1452

performer

S Σ C

0..*

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Element id

DiagnosticReport.performer

Short description

Durchführende Stelle

Alternate names

Laboratory, Service, Practitioner, Department, Company, Authorized by, Director, Labor / Institution/ Ansprechpartner

Definition

Das Labor oder die Institution die den Bericht erstellt hat

Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Comments

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

Data type

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.actor
v2: PRT-8 (where this PRT-4-Participation = "PO")
rim: .participation[typeCode=PRF]
MII-KDS: mide-dataelement-1453

resultsInterpreter

S Σ C

0..*

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Element id

DiagnosticReport.resultsInterpreter

Short description

Befundinterpreter

Alternate names

Analyzed by, Reported by, Labor / Institution/ Ansprechpartner

Definition

Die Person oder Organisation die die Ergebnisse interpretiert hat

Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Comments

Might not be the same entity that takes responsibility for the clinical report.

Data type

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.actor
v2: OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
rim: .participation[typeCode=PRF]
MII-KDS: mide-dataelement-1453

specimen

S C

0..*

Reference(Specimen)

Element id

DiagnosticReport.specimen

Short description

Probe

Definition

Die untersuchte Probe

Requirements

Need to be able to report information about the collected specimens on which the report is based.

Comments

If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.

Data type

Reference(Specimen)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: SPM
rim: participation[typeCode=SBJ]

result

S C

0..*

Reference(Observation)

Element id

DiagnosticReport.result

Short description

Ergebnis

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenzen zu den einzelnen Beobachtungsergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(Observation)

Slicing

Unordered, Open, by resolve()(Profile)

Slice based on the reference profile and code pattern

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

diagnostic-implication

S C

0..*

Reference(MII_PR_MolGen_DiagnostischeImplikation)

Element id

DiagnosticReport.result:diagnostic-implication

Short description

Diagnostische Implikation

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu diagnostischen Implikationen der genetischen Befunde

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_DiagnostischeImplikation)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

therapeutic-implication

S C

0..*

Reference(MII_PR_MolGen_TherapeutischeImplikation)

Element id

DiagnosticReport.result:therapeutic-implication

Short description

Therapeutische Implikation

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu therapeutischen Implikationen der genetischen Befunde

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_TherapeutischeImplikation)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

molecular-consequence

0..*

Reference(MolecularConsequence)

There are no (further) constraints on this element

Element id

DiagnosticReport.result:molecular-consequence

Short description

Molecular Consequence

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Observations that are part of this diagnostic report.

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MolecularConsequence)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

variant

S C

0..*

Reference(MII_PR_MolGen_Variante)

Element id

DiagnosticReport.result:variant

Short description

Variante

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu gefundenen genetischen Varianten

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_Variante)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

sequence-phase-relation

S C

0..*

Reference(SequencePhaseRelationship)

Element id

DiagnosticReport.result:sequence-phase-relation

Short description

Sequenz-Phasen-Beziehung

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Sequenz-Phasen-Beziehungen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(SequencePhaseRelationship)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

genotype

S C

0..*

Reference(MII_PR_MolGen_Genotyp)

Element id

DiagnosticReport.result:genotype

Short description

Genotyp

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Genotyp-Ergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_Genotyp)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

haplotype

S C

0..*

Reference(Haplotype)

Element id

DiagnosticReport.result:haplotype

Short description

Haplotyp

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Haplotyp-Ergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(Haplotype)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

biomarker

S C

0..*

Reference(MolecularBiomarker)

Element id

DiagnosticReport.result:biomarker

Short description

Biomarker

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu molekularen Biomarkern wie TMB oder MSI

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MolecularBiomarker)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

imagingStudy

0..*

Reference(ImagingStudy)

There are no (further) constraints on this element

Element id

DiagnosticReport.imagingStudy

Short description

Reference to full details of imaging associated with the diagnostic report

Definition

One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.

Comments

ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.

Data type

Reference(ImagingStudy)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]

media

S Σ

0..*

BackboneElement

Element id

DiagnosticReport.media

Short description

Medien

Alternate names

DICOM, Slides, Scans

Definition

Bilder oder andere Medien die zum Bericht gehören

Requirements

Many diagnostic services include images in the report as part of their service.

Data type

BackboneElement

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: OBX?
rim: outboundRelationship[typeCode=COMP].target
MII-KDS: mide-dataelement-1698
MII-KDS: mide-dataelement-1447

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.media.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

string

Mappings

rim: n/a

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.media.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.media.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Extension

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

comment

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.media.comment

Short description

Comment about the image (e.g. explanation)

Definition

A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.

Requirements

The provider of the report should make a comment about each image included in the report.

Comments

The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value

link

Σ C

1..1

Reference(Media)

There are no (further) constraints on this element

Element id

DiagnosticReport.media.link

Short description

Reference to the image source

Definition

Reference to the image source.

Comments

Data type

Reference(Media)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .value.reference

conclusion

0..1

string

Element id

DiagnosticReport.conclusion

Short description

Schlussfolgerung

Alternate names

Report

Definition

Textuelle Zusammenfassung der Befundergebnisse

Requirements

Need to be able to provide a conclusion that is not lost among the basic result data.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: OBX
rim: inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)

conclusionCode

0..*

CodeableConcept

Element id

DiagnosticReport.conclusionCode

Short description

Schlussfolgerungscode

Definition

Kodierte Schlussfolgerung des Befundes

Comments

Data type

CodeableConcept

Binding

Diagnosis codes provided as adjuncts to the report.

SNOMEDCTClinicalFindings (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
v2: OBX
rim: inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)

presentedForm

0..*

Attachment

There are no (further) constraints on this element

Element id

DiagnosticReport.presentedForm

Short description

Entire report as issued

Definition

Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.

Requirements

Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.

Comments

"application/pdf" is recommended as the most reliable and interoperable in this context.

Data type

Attachment

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
att-1: If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()

Mappings

rim: n/a
v2: ED/RP
rim: ED
v2: OBX
rim: text (type=ED)

Snapshot

MII_PR_MolGen_MolekulargenetischerBefundbericht (DiagnosticReport)

GenomicReport

Element id

DiagnosticReport

Short description

A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports

Alternate names

Report, Test, Result, Results, Labs, Laboratory

Definition

Comments

Data type

GenomicReport

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: 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-3: 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-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
v2: ORU -> OBR
rim: Observation[classCode=OBS, moodCode=EVN]
MII-KDS: mide-dataelement-1371

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

string

Meta

There are no (further) constraints on this element

Element id

DiagnosticReport.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Meta

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

uri

There are no (further) constraints on this element

Element id

DiagnosticReport.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

uri

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

DiagnosticReport.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

code

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

Narrative

There are no (further) constraints on this element

Element id

DiagnosticReport.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Narrative

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

Resource

There are no (further) constraints on this element

Element id

DiagnosticReport.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Resource

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

recommended-action

S C

0..*

Extension(Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme | MII_PR_MolGen_Medikationsempfehlung))

Element id

DiagnosticReport.extension:recommended-action

Short description

Empfohlene Maßnahme

Alternate names

extensions, user content

Definition

Referenz zu empfohlenen Folgemaßnahmen oder Medikationsempfehlungen

Comments

Data type

Extension(Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme | MII_PR_MolGen_Medikationsempfehlung))

Extension URL

https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/empfohlene-massnahme

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

genomic-risk-assessment

S C

0..*

Extension(Reference(RiskAssessment))

Element id

DiagnosticReport.extension:genomic-risk-assessment

Short description

Genomische Risikobewertung

Alternate names

extensions, user content

Definition

Referenz zu einer genomischen Risikobewertung

Comments

Data type

Extension(Reference(RiskAssessment))

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-risk-assessment

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coded-note

S C

0..*

Extension(CodedAnnotation)

Element id

DiagnosticReport.extension:coded-note

Short description

Kodierte Anmerkung

Alternate names

extensions, user content

Definition

Kodierte Anmerkungen zum genetischen Bericht

Requirements

Need to be able to provide free text additional information. Notes SHALL NOT contain information which can be captured in a structured way.

Comments

Data type

Extension(CodedAnnotation)

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-report-note

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

supporting-info

S C

0..*

Extension(Reference(Resource))

Element id

DiagnosticReport.extension:supporting-info

Short description

Unterstützende Informationen

Alternate names

extensions, user content

Definition

Zusätzliche unterstützende Informationen wie Familienanamnese oder Abrechnungsdaten

Comments

Data type

Extension(Reference(Resource))

Extension URL

http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

genomic-study

S C

0..*

Extension(Reference(GenomicStudy))

Element id

DiagnosticReport.extension:genomic-study

Short description

Genomische Studie

Alternate names

extensions, user content

Definition

Referenz zur zugehörigen genomischen Studie

Comments

Data type

Extension(Reference(GenomicStudy))

Extension URL

http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-study-reference

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

hla-genotyping-results-allele-database

0..1

Extension(CodeableConcept)

There are no (further) constraints on this element

Element id

DiagnosticReport.extension:hla-genotyping-results-allele-database

Short description

Allele Database

Alternate names

extensions, user content

Definition

Allele Database.

Comments

Data type

Extension(CodeableConcept)

Extension URL

http://hl7.org/fhir/StructureDefinition/hla-genotyping-results-allele-database

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

hla-genotyping-results-glstring

0..1

Extension(Complex)

There are no (further) constraints on this element

Element id

DiagnosticReport.extension:hla-genotyping-results-glstring

Short description

glstring

Alternate names

extensions, user content

Definition

glstring.

Comments

Data type

Extension(Complex)

Extension URL

http://hl7.org/fhir/StructureDefinition/hla-genotyping-results-glstring

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

workflow-relatedArtifact

S C

0..*

Extension(RelatedArtifact)

Element id

DiagnosticReport.extension:workflow-relatedArtifact

Short description

Verknüpfte Artefakte

Alternate names

extensions, user content

Definition

Verknüpfte Literatur oder andere Artefakte wie Zitationen

Comments

Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource.

Data type

Extension(RelatedArtifact)

Extension URL

http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

identifier

0..*

Identifier

There are no (further) constraints on this element

Element id

DiagnosticReport.identifier

Short description

Business identifier for report

Alternate names

ReportID, Filler ID, Placer ID

Definition

Identifiers assigned to this report by the performer or other systems.

Requirements

Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.

Comments

Usually assigned by the Information System of the diagnostic service provider (filler id).

Data type

Identifier

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
v2: OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4
rim: id

basedOn

0..*

Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)

There are no (further) constraints on this element

Element id

DiagnosticReport.basedOn

Short description

What was requested

Alternate names

Request

Definition

Details concerning a service requested.

Requirements

This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.

Comments

Data type

Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.basedOn
v2: ORC? OBR-2/3?
rim: outboundRelationship[typeCode=FLFS].target

status

S Σ ?!

1..1

codeBinding

Element id

DiagnosticReport.status

Short description

Status

Alternate names

Berichtstatus

Definition

Status des Befundberichts

Requirements

Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

code

Binding

The status of the diagnostic report.

DiagnosticReportStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
v2: OBR-25 (not 1:1 mapping)
rim: statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
MII-KDS: mide-dataelement-1448

category

1..*

CodeableConcept

There are no (further) constraints on this element

Element id

DiagnosticReport.category

Short description

Service category

Alternate names

Department, Sub-department, Service, Discipline

Definition

Comments

Data type

CodeableConcept

Slicing

Unordered, Open, by coding(Value)

Slice based on the category code pattern

Binding

Codes for diagnostic service sections.

DiagnosticServiceSectionCodes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
w5: FiveWs.class
v2: OBR-24
rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code

Genetics

1..1

CodeableConcept

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics

Short description

Service category

Alternate names

Department, Sub-department, Service, Discipline

Definition

Comments

Data type

CodeableConcept

Binding

Codes for diagnostic service sections.

DiagnosticServiceSectionCodes (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
w5: FiveWs.class
v2: OBR-24
rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

string

Mappings

rim: n/a

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

1..1

CodingPattern

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Coding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "system": "http://terminology.hl7.org/CodeSystem/v2-0074",
  "code": "GE"
}

Mappings

rim: n/a
v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
rim: CV
orim: fhir:Coding rdfs:subClassOf dt:CDCoding
v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding

text

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.category:Genetics.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

code

1..1

CodeableConceptBindingPattern

There are no (further) constraints on this element

Element id

DiagnosticReport.code

Short description

Name/Code for this diagnostic report

Alternate names

Type

Definition

A code or name that describes this diagnostic report.

Comments

Data type

CodeableConcept

Binding

Codes that describe Diagnostic Reports.

LOINCDiagnosticReportCodes (preferred)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "coding": [
    {
      "system": "http://loinc.org",
      "code": "51969-4"
    }
  ]
}

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.what[x]
v2: OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)
rim: code

subject

S Σ C

1..1

Reference(Group | Patient)

Element id

DiagnosticReport.subject

Short description

Patient

Alternate names

Patient

Definition

Der Patient auf den sich der Befundbericht bezieht

Requirements

SHALL know the subject context.

Comments

Data type

Reference(Group | Patient)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.subject
w5: FiveWs.subject[x]
v2: PID-3 (no HL7 v2 mapping for Group or Device)
rim: participation[typeCode=SBJ]
w5: FiveWs.subject

encounter

S Σ C

0..1

Reference(Encounter)

Element id

DiagnosticReport.encounter

Short description

Kontakt

Alternate names

Context

Definition

Der Kontakt in dessen Rahmen der Bericht erstellt wurde

Requirements

Links the request to the Encounter context.

Comments

Data type

Reference(Encounter)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.encounter
w5: FiveWs.context
v2: PV1-19
rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]

effective[x]

0..1

There are no (further) constraints on this element

Element id

DiagnosticReport.effective[x]

Short description

Clinically relevant time/time-period for report

Alternate names

Observation time, Effective Time, Occurrence

Definition

Requirements

Need to know where in the patient history to file/present this report.

Comments

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.done[x]
v2: OBR-7
rim: effectiveTime

effectiveDateTime

dateTime

There are no (further) constraints on this element

Data type

dateTime

issued

S Σ

0..1

instant

Element id

DiagnosticReport.issued

Short description

Freigabedatum

Alternate names

Date published, Date Issued, Date Verified, Datum des Berichtes

Definition

Datum und Uhrzeit der Freigabe des Berichts

Requirements

Clinicians need to be able to check the date that the report was released.

Comments

May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.

Data type

instant

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.recorded
v2: OBR-22
rim: participation[typeCode=VRF or AUT].time
MII-KDS: mide-dataelement-1452

performer

S Σ C

0..*

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Element id

DiagnosticReport.performer

Short description

Durchführende Stelle

Alternate names

Laboratory, Service, Practitioner, Department, Company, Authorized by, Director, Labor / Institution/ Ansprechpartner

Definition

Das Labor oder die Institution die den Bericht erstellt hat

Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Comments

This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.

Data type

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.actor
v2: PRT-8 (where this PRT-4-Participation = "PO")
rim: .participation[typeCode=PRF]
MII-KDS: mide-dataelement-1453

resultsInterpreter

S Σ C

0..*

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Element id

DiagnosticReport.resultsInterpreter

Short description

Befundinterpreter

Alternate names

Analyzed by, Reported by, Labor / Institution/ Ansprechpartner

Definition

Die Person oder Organisation die die Ergebnisse interpretiert hat

Requirements

Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.

Comments

Might not be the same entity that takes responsibility for the clinical report.

Data type

Reference(CareTeam | Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.actor
v2: OBR-32, PRT-8 (where this PRT-4-Participation = "PI")
rim: .participation[typeCode=PRF]
MII-KDS: mide-dataelement-1453

specimen

S C

0..*

Reference(Specimen)

Element id

DiagnosticReport.specimen

Short description

Probe

Definition

Die untersuchte Probe

Requirements

Need to be able to report information about the collected specimens on which the report is based.

Comments

Data type

Reference(Specimen)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: SPM
rim: participation[typeCode=SBJ]

result

S C

0..*

Reference(Observation)

Element id

DiagnosticReport.result

Short description

Ergebnis

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenzen zu den einzelnen Beobachtungsergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(Observation)

Slicing

Unordered, Open, by resolve()(Profile)

Slice based on the reference profile and code pattern

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

diagnostic-implication

S C

0..*

Reference(MII_PR_MolGen_DiagnostischeImplikation)

Element id

DiagnosticReport.result:diagnostic-implication

Short description

Diagnostische Implikation

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu diagnostischen Implikationen der genetischen Befunde

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_DiagnostischeImplikation)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

therapeutic-implication

S C

0..*

Reference(MII_PR_MolGen_TherapeutischeImplikation)

Element id

DiagnosticReport.result:therapeutic-implication

Short description

Therapeutische Implikation

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu therapeutischen Implikationen der genetischen Befunde

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_TherapeutischeImplikation)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

molecular-consequence

0..*

Reference(MolecularConsequence)

There are no (further) constraints on this element

Element id

DiagnosticReport.result:molecular-consequence

Short description

Molecular Consequence

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Observations that are part of this diagnostic report.

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MolecularConsequence)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

variant

S C

0..*

Reference(MII_PR_MolGen_Variante)

Element id

DiagnosticReport.result:variant

Short description

Variante

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu gefundenen genetischen Varianten

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_Variante)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

sequence-phase-relation

S C

0..*

Reference(SequencePhaseRelationship)

Element id

DiagnosticReport.result:sequence-phase-relation

Short description

Sequenz-Phasen-Beziehung

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Sequenz-Phasen-Beziehungen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(SequencePhaseRelationship)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

genotype

S C

0..*

Reference(MII_PR_MolGen_Genotyp)

Element id

DiagnosticReport.result:genotype

Short description

Genotyp

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Genotyp-Ergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MII_PR_MolGen_Genotyp)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

haplotype

S C

0..*

Reference(Haplotype)

Element id

DiagnosticReport.result:haplotype

Short description

Haplotyp

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu Haplotyp-Ergebnissen

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(Haplotype)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

biomarker

S C

0..*

Reference(MolecularBiomarker)

Element id

DiagnosticReport.result:biomarker

Short description

Biomarker

Alternate names

Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer

Definition

Referenz zu molekularen Biomarkern wie TMB oder MSI

Requirements

Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.

Comments

Observations can contain observations.

Data type

Reference(MolecularBiomarker)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: OBXs
rim: outboundRelationship[typeCode=COMP].target

imagingStudy

0..*

Reference(ImagingStudy)

There are no (further) constraints on this element

Element id

DiagnosticReport.imagingStudy

Short description

Reference to full details of imaging associated with the diagnostic report

Definition

Comments

Data type

Reference(ImagingStudy)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]

media

S Σ

0..*

BackboneElement

Element id

DiagnosticReport.media

Short description

Medien

Alternate names

DICOM, Slides, Scans

Definition

Bilder oder andere Medien die zum Bericht gehören

Requirements

Many diagnostic services include images in the report as part of their service.

Data type

BackboneElement

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: OBX?
rim: outboundRelationship[typeCode=COMP].target
MII-KDS: mide-dataelement-1698
MII-KDS: mide-dataelement-1447

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.media.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

string

Mappings

rim: n/a

extension

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.media.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Extension

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

Extension

There are no (further) constraints on this element

Element id

DiagnosticReport.media.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Extension

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

comment

0..1

string

There are no (further) constraints on this element

Element id

DiagnosticReport.media.comment

Short description

Comment about the image (e.g. explanation)

Definition

A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.

Requirements

The provider of the report should make a comment about each image included in the report.

Comments

The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value

link

Σ C

1..1

Reference(Media)

There are no (further) constraints on this element

Element id

DiagnosticReport.media.link

Short description

Reference to the image source

Definition

Reference to the image source.

Comments

Data type

Reference(Media)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
rim: .value.reference

conclusion

0..1

string

Element id

DiagnosticReport.conclusion

Short description

Schlussfolgerung

Alternate names

Report

Definition

Textuelle Zusammenfassung der Befundergebnisse

Requirements

Need to be able to provide a conclusion that is not lost among the basic result data.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

string

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: OBX
rim: inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)

conclusionCode

0..*

CodeableConcept

Element id

DiagnosticReport.conclusionCode

Short description

Schlussfolgerungscode

Definition

Kodierte Schlussfolgerung des Befundes

Comments

Data type

CodeableConcept

Binding

Diagnosis codes provided as adjuncts to the report.

SNOMEDCTClinicalFindings (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
v2: OBX
rim: inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)

presentedForm

0..*

Attachment

There are no (further) constraints on this element

Element id

DiagnosticReport.presentedForm

Short description

Entire report as issued

Definition

Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.

Requirements

Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.

Comments

"application/pdf" is recommended as the most reliable and interoperable in this context.

Data type

Attachment

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
att-1: If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()

Mappings

rim: n/a
v2: ED/RP
rim: ED
v2: OBX
rim: text (type=ED)

Extensions

Genomics Artifact

Name: Genomics Artifact
Definition: Erfasst Zitate, Beweise und andere unterstützende Unterlagen für die Beobachtung oder den Bericht.
url: http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-artifact

Snapshot

Command 'tree' could not render: Resource was not found for 'canonical=http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-artifact'

Genomics File

Name: Genomics File
Definition: Wird verwendet, um den Inhalt von oder Links zu Dateien zu übermitteln, die als Teil des Testprozesses erstellt wurden. Beispiele sind VCF-, BAM-, CRAM- und andere ähnliche Dateien.
url: http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-file

Snapshot

Command 'tree' could not render: Resource was not found for 'canonical=http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-file'

Empfohlene Maßnahme

Name: Empfohlene Maßnahme
Definition: Die Extension verweist auf eine vorgeschlagene Maßnahme, die auf der Grundlage der Ergebnisse des Befundberichts empfohlen wird.
url: https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/empfohlene-massnahme

Snapshot

MII_EX_MolGen_EmpfohleneMassnahme (Extension)	C		RecommendedAction	Element id Extension Short description MII EX MolGen Empfohlene Maßnahme Definition Die Extension verweist auf eine vorgeschlagene Maßnahme, die auf der Grundlage der Ergebnisse des Befundberichts empfohlen wird. Data type RecommendedAction Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
id		0..1	string	There are no (further) constraints on this element Element id Extension.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..0	Extension	There are no (further) constraints on this element Element id Extension.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
url		1..1	uriFixed Value	There are no (further) constraints on this element Element id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data type uri Fixed value http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/recommended-action Mappings rim: N/A
value[x]		0..1		There are no (further) constraints on this element Element id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
valueReference			Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme \| MII_PR_MolGen_Medikationsempfehlung)	Data type Reference(MII_PR_MolGen_EmpfohleneFolgemassnahme \| MII_PR_MolGen_Medikationsempfehlung)

Genomics Risk Assessment

Name: Genomics Risk Assessment
Definition: RiskAssessment als Teil eines genomischen Berichtes oder einer Beobachtung.
url: http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-risk-assessment

Snapshot

Command 'tree' could not render: Resource was not found for 'canonical=http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomics-risk-assessment'

Coded Note

Name: Coded Note
Definition: Kommentare zum Bericht, die auch einen kodierten Typ enthalten.
url: http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-report-note

Snapshot

GenomicReportNote (Extension)	C		Extension	Element id Extension Short description Genomic Report Note Definition Adds codified notes to a report to capture additional content Data type Extension Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
id		0..1	string	There are no (further) constraints on this element Element id Extension.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..0	Extension	There are no (further) constraints on this element Element id Extension.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
url		1..1	uriFixed Value	Element id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data type uri Fixed value http://hl7.org/fhir/uv/genomics-reporting/StructureDefinition/genomic-report-note Mappings rim: N/A
value[x]		0..1		Element id Extension.value[x] Short description Text node with attribution Definition A text note which also contains information about who made the statement and when. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A v2: N/A rim: Act
valueAnnotation			CodedAnnotation	Data type CodedAnnotation

Supporting Info

Name: Supporting Info
Definition: Weitere Informationen, die für diese Beobachtung relevant sein könnten.
url: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo

Snapshot

supportingInfo (Extension)	C		Extension	Element id Extension Short description Other information that may be relevant to this event. Definition Other resources from the patient record that may be relevant to the event. The information from these resources was either used to create the instance or is provided to help with its interpretation. This extension should not be used if more specific inline elements or extensions are available. For example, use `Observation.hasMember` instead of supportingInformation for representing the members of an Observation panel. Data type Extension Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
id		0..1	string	There are no (further) constraints on this element Element id Extension.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	C	0..0	Extension	There are no (further) constraints on this element Element id Extension.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Comments There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Data type Extension Slicing Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a rim: N/A
url		1..1	uriFixed Value	Element id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data type uri Fixed value http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo Mappings rim: N/A
value[x]		1..1		There are no (further) constraints on this element Element id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Conditions The cardinality or value of this element may be affected by these constraints: ele-1 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
valueReference			Reference(Resource)	Data type Reference(Resource)

FHIR-Element	Logischer Datensatz
DiagnosticReport.status	Weiteres.Berichtstatus
DiagnosticReport.issued	Weiteres.Datum des Berichts
DiagnosticReport.performer	Weiteres.Labor / Institution/ Ansprechpartner
DiagnosticReport.resultsInterpreter	Weiteres.Labor / Institution/ Ansprechpartner
DiagnosticReport.media	Ergebnisse.Daten
DiagnosticReport.media	Weiteres.Anhänge
DiagnosticReport.subject	Probeninformationen.Patient
DiagnosticReport.specimen	Probeninformationen.Probe
DiagnosticReport.identifier	Weiteres.Bericht ID
DiagnosticReport.extension:supporting-info(ChargeItem)	Anforderung.Einheitlicher Bewertungsmaßstab
DiagnosticReport.supporting-info	Methoden.Relevante Parameter

Suchparameter

Folgende Suchparameter sind für das Modul Pathologie-Befund relevant, auch in Kombination:

Der Suchparameter _id MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?_id=example-mii-molgen-molekulargenetischer-befundbericht-1

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/molekulargenetischer-befundbericht

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "code" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?code=http://loinc.org|51969-4

Anwendungshinweise: Weitere Informationen zur Suche nach "code" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "subject" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?subject=Patient/example-mii-molgen-patient

Anwendungshinweise: Weitere Informationen zur Suche nach "subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "category" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?category=http://terminology.hl7.org/CodeSystem/v2-0074|GE

Anwendungshinweise: Weitere Informationen zur Suche nach "category" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "encounter" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?encounter=Encounter/12345

Anwendungshinweise: Weitere Informationen zur Suche nach "encounter" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "date" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?date=2022-07-13

Anwendungshinweise: Weitere Informationen zur Suche nach "date" finden sich in der FHIR-Basisspezifikation - Abschnitt "date".
Der Suchparameter "issued" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?issued=2022-07-13

Anwendungshinweise: Weitere Informationen zur Suche nach "issued" finden sich in der FHIR-Basisspezifikation - Abschnitt "date".
Der Suchparameter "performer" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?performer=Practioner/example-mii-molgen-practitioner-laboratory

Anwendungshinweise: Weitere Informationen zur Suche nach "performer" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "requestor" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?requestor=Practioner/example-mii-molgen-practitioner-physician

Anwendungshinweise: Weitere Informationen zur Suche nach "requestor" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "specimen" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?specimen=Specimen/example-mii-molgen-specimen

Anwendungshinweise: Weitere Informationen zur Suche nach "specimen" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "status" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?status=final

Anwendungshinweise: Weitere Informationen zur Suche nach "status" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "result" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?result=Observation/example-mii-molgen-variante-1

Anwendungshinweise: Weitere Informationen zur Suche nach "result" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "media" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?media=Media/12345

Anwendungshinweise: Weitere Informationen zur Suche nach "media" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "conclusion" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?conclusion=http://snomed.info/sct|830150003

Anwendungshinweise: Weitere Informationen zur Suche nach "conclusion" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".

Examples

Befundbericht-1 BRAF

Command 'json' could not render: File not found for 'subject=example-mii-molgen-molekulargenetischer-befundbericht-1'

Befundbericht-2 NIPBL

Command 'json' could not render: File not found for 'subject=example-mii-molgen-molekulargenetischer-befundbericht-2'

Die in Befundbericht-2 abzurechnenden EBM-Ziffern werden separat in ChargeItem Ressourcen erfasst.

{

"resourceType": "ChargeItem",

"id": "mii-exa-molgen-chargeitem-ebm-21",

"meta": {

"profile": [

"http://fhir.de/StructureDefinition/chargeitem-de-ebm"

]

"status": "billable",

"code": {

"coding": [

{

"system": "https://fhir.kbv.de/NamingSystem/KBV_NS_Base_EBM",
"code": "11513",
"display": "Postnatale Mutationssuche zum Nachweis oder Ausschluss einer krankheitsrelevanten oder krankheitsauslösenden konstitutionellen genomischen Mutation"

}

]

"subject": {

"reference": "Patient/mii-exa-molgen-patient-2"

"quantity": {

"value": 72

}

Befundbericht-3 Risk-Panel

Command 'json' could not render: File not found for 'subject=mii-exa-molgen-molekulargenetischer-befundbericht-brca1'