MII IG Molekulares Tumorboard DE v2025

Histologie-Evaluation (Auftrag): ServiceRequest

Inhalt

Dieses Profil beschreibt eine Empfehlung zur histologischen Reevaluation.

Dies kann u.a. erfolgen, wenn die ursprüngliche Befundung nicht aussagekräftig war oder aufgrund bestimmter Marker eine spezifisches Nachweisverfahren für Proteine (z.B. per IHC), Nukleinsäuren (z.B. per ISH) oder anderer Spezialfärbungen erforderlich werden.

Statusangabe

Die Statusangabe eines Auftrags zur Histologie-Evaluation bezieht sich auf dessen Umsetzungsstand. Es wird empfohlen folgende Statusangaben für die beschriebenen Situationen zu verwenden:

Belegung `status`	Beschreibung
`draft`	Nicht umgesetzt
`active`	In Umsetzung
`completed`	Abgeschlossen oder abgebrochen (Patient verstorben)

Hinweis: Die Statusangabe sollte mit der des beschlossenen Therapieplans (siehe Therapieplan: CarePlan) semantisch abgestimmt sein.

Zeitliche Zuordnung im Verlauf

Name	Status	Version	Canonical	Basis
MII_PR_MTB_Histologie_Evaluation_Auftrag	draft	2024.0.0-ballot	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-histologie-evaluation-auftrag	http://hl7.org/fhir/StructureDefinition/ServiceRequest

Inhalt

MII_PR_MTB_Histologie_Evaluation_Auftrag (ServiceRequest)	I		ServiceRequest	There are no (further) constraints on this element Element id ServiceRequest Short description A request for a service to be performed Alternate names diagnostic request, referral, referral request, transfer of care request Definition A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. Data type ServiceRequest Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.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-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-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() prr-1: orderDetail SHALL only be present if code is present `orderDetail.empty() or code.exists()` Mappings rim: Entity. Role, or Act workflow: Request v2: ORC rim: Act[moodCode<=INT]
id	Σ	0..1	string	There are no (further) constraints on this element Element id ServiceRequest.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	S Σ	0..1	Meta	There are no (further) constraints on this element Element id ServiceRequest.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id ServiceRequest.meta.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	I	0..*	Extension	There are no (further) constraints on this element Element id ServiceRequest.meta.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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id ServiceRequest.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id ServiceRequest.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
source	Σ	0..1	uri	There are no (further) constraints on this element Element id ServiceRequest.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id ServiceRequest.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id ServiceRequest.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id ServiceRequest.meta.tag Short description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id ServiceRequest.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id ServiceRequest.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) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id ServiceRequest.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id ServiceRequest.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: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id ServiceRequest.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 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
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id ServiceRequest.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 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 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
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id ServiceRequest.identifier Short description Identifiers assigned to this order Definition Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. Comments The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.identifier w5: FiveWs.identifier v2: ORC.2, ORC.3, RF1-6 / RF1-11, rim: .identifier quick: ClinicalStatement.identifier
instantiatesCanonical	Σ	0..*	canonical(ActivityDefinition \| PlanDefinition)	There are no (further) constraints on this element Element id ServiceRequest.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. Data type canonical(ActivityDefinition \| PlanDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.instantiatesCanonical v2: Varies by domain rim: .outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element id ServiceRequest.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.instantiatesUri v2: Varies by domain rim: .outboundRelationship[typeCode=DEFN].target
basedOn	Σ	0..*	Reference(CarePlan \| ServiceRequest \| MedicationRequest)	There are no (further) constraints on this element Element id ServiceRequest.basedOn Short description What request fulfills Alternate names fulfills Definition Plan/proposal/order fulfilled by this request. Data type Reference(CarePlan \| ServiceRequest \| MedicationRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.basedOn v2: ORC.8 (plus others) rim: .outboundRelationship[typeCode=FLFS].target
replaces	Σ	0..*	Reference(ServiceRequest)	There are no (further) constraints on this element Element id ServiceRequest.replaces Short description What request replaces Alternate names supersedes, prior, renewed order Definition The request takes the place of the referenced completed or terminated request(s). Data type Reference(ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.replaces v2: Handled by message location of ORC (ORC.1=RO or RU) rim: .outboundRelationship[typeCode=RPLC].target
requisition	Σ	0..1	Identifier	There are no (further) constraints on this element Element id ServiceRequest.requisition Short description Composite Request ID Alternate names grouperId, groupIdentifier Definition A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Requirements Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Comments Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.groupIdentifier v2: ORC.4 rim: .inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier
status	Σ ?!	1..1	codeBinding	Element id ServiceRequest.status Short description draft \| active \| on-hold \| revoked \| completed \| entered-in-error \| unknown Definition Status der Umsetzung der Empfehlung Comments draft: Nicht umgesetzt, active: In Umsetzung, completed: Abgeschlossen oder abgebrochen (Patient verstorben) Data type code Binding The status of a service order. RequestStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.status w5: FiveWs.status v2: ORC.5,RF1-1 rim: .status quick: Action.currentStatus
intent	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id ServiceRequest.intent Short description proposal \| plan \| directive \| order \| original-order \| reflex-order \| filler-order \| instance-order \| option Definition Whether the request is a proposal, plan, an original order or a reflex order. Comments This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. Data type code Binding The kind of service request. RequestIntent (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.intent w5: FiveWs.class v2: N/A rim: .moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)
category	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.category Short description Classification of service Definition A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Requirements Used for filtering what service request are retrieved and displayed. Comments There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Data type CodeableConcept Binding Classification of the requested service. ServiceRequestCategoryCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class v2: RF1-5 rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="INT"].code
priority	Σ	0..1	codeBinding	There are no (further) constraints on this element Element id ServiceRequest.priority Short description routine \| urgent \| asap \| stat Definition Indicates how quickly the ServiceRequest should be addressed with respect to other requests. Meaning when missing If missing, this task should be performed with normal priority Data type code Binding Identifies the level of importance to be assigned to actioning the request. RequestPriority (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.priority w5: FiveWs.grade v2: TQ1.9, RF1-2 rim: .priorityCode
doNotPerform	Σ ?!	0..1	boolean	There are no (further) constraints on this element Element id ServiceRequest.doNotPerform Short description True if service/procedure should not be performed Definition Set this to true if the record is saying that the service/procedure should NOT be performed. Requirements Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. Comments In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation. Meaning when missing If missing, the request is a positive request e.g. "do perform" Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.doNotPerform rim: .actionNegationInd
code	S Σ	1..1	CodeableConcept	Element id ServiceRequest.code Short description Empfehlung zur histologischen (Re-)Evaluation Alternate names service requested Definition Empfehlung zur histologischen (Re-)Evaluation Comments Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Data type CodeableConcept Binding Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available here. ProcedureCodes(SNOMEDCT) (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.code w5: FiveWs.what[x] v2: PR1-3 / OBR-4 (varies by domain) rim: .code quick: Procedure.procedureCode
id		0..1	string	There are no (further) constraints on this element Element id ServiceRequest.code.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	I	0..*	Extension	There are no (further) constraints on this element Element id ServiceRequest.code.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 Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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
coding	Σ	0..*	CodingPattern	Element id ServiceRequest.code.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://snomed.info/sct", "code": "183825009", "display": "Refer for histology (procedure)" } Mappings v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	0..1	string	There are no (further) constraints on this element Element id ServiceRequest.code.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 Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
orderDetail	Σ I	0..*	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.orderDetail Short description Additional order information Alternate names detailed instructions Definition Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. Comments For information from the medical record intended to support the delivery of the requested services, use the `supportingInformation` element. Data type CodeableConcept Binding Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: NTE rim: .code quick: Procedure.procedureCode
quantity[x]	Σ	0..1		There are no (further) constraints on this element Element id ServiceRequest.quantity[x] Short description Service amount Definition An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). Requirements When ordering a service the number of service items may need to be specified separately from the the service item. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: NTE rim: .quantity
quantityQuantity			Quantity	There are no (further) constraints on this element Data type Quantity
quantityRatio			Ratio	There are no (further) constraints on this element Data type Ratio
quantityRange			Range	There are no (further) constraints on this element Data type Range
subject	Σ	1..1	Reference(Patient \| Group \| Location \| Device)	There are no (further) constraints on this element Element id ServiceRequest.subject Short description Individual or Entity the service is ordered for Definition On whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). Data type Reference(Patient \| Group \| Location \| Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.subject w5: FiveWs.subject[x] v2: PID rim: .participation[typeCode=SBJ].role quick: ClinicalStatement.subject w5: FiveWs.subject
encounter	Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id ServiceRequest.encounter Short description Encounter in which the request was created Alternate names context Definition An encounter that provides additional information about the healthcare context in which this request is made. Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.encounter w5: FiveWs.context v2: PV1 rim: .inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN] quick: ClinicalStatement.encounter
occurrence[x]	Σ	0..1		There are no (further) constraints on this element Element id ServiceRequest.occurrence[x] Short description When service should occur Alternate names schedule Definition The date/time at which the requested service should occur. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.occurrence[x] w5: FiveWs.planned v2: TQ1/TQ2, OBR-7/OBR-8 rim: .effectiveTime quick: Procedure.procedureSchedule
occurrenceDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
occurrencePeriod			Period	There are no (further) constraints on this element Data type Period
occurrenceTiming			Timing	There are no (further) constraints on this element Data type Timing
asNeeded[x]	Σ	0..1		There are no (further) constraints on this element Element id ServiceRequest.asNeeded[x] Short description Preconditions for service Definition If a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. Binding A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code="Assertion"].value quick: Proposal.prnReason.reason
asNeededBoolean			boolean	There are no (further) constraints on this element Data type boolean
asNeededCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
authoredOn	Σ	0..1	dateTime	There are no (further) constraints on this element Element id ServiceRequest.authoredOn Short description Date request signed Alternate names orderedOn Definition When the request transitioned to being actionable. Data type dateTime Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.authoredOn w5: FiveWs.recorded v2: ORC.9, RF1-7 / RF1-9 rim: .participation[typeCode=AUT].time quick: Proposal.proposedAtTime
requester	Σ	0..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	There are no (further) constraints on this element Element id ServiceRequest.requester Short description Who/what is requesting service Alternate names author, orderer Definition The individual who initiated the request and has responsibility for its activation. Comments This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource. Data type Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.requester w5: FiveWs.author v2: ORC.12, PRT rim: .participation[typeCode=AUT].role quick: ClinicalStatement.statementAuthor
performerType	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.performerType Short description Performer role Alternate names specialty Definition Desired type of performer for doing the requested service. Comments This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Data type CodeableConcept Binding Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.performerType w5: FiveWs.actor v2: PRT, RF!-3 rim: .participation[typeCode=PRF].role[scoper.determinerCode=KIND].code
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson)	There are no (further) constraints on this element Element id ServiceRequest.performer Short description Requested performer Alternate names request recipient Definition The desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. Comments If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Data type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.performer w5: FiveWs.actor v2: PRT, Practitioner: PRD-2/PRD-7 where PRD-3 = RT; Organization: PRD-10 where PRD-3 = RT rim: .participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]
locationCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.locationCode Short description Requested location Definition The preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Data type CodeableConcept Binding A location type where services are delivered. v3.ServiceDeliveryLocationRoleType (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.actor rim: .participation[typeCode=LOC].role[scoper.determinerCode=KIND].code
locationReference	Σ	0..*	Reference(Location)	There are no (further) constraints on this element Element id ServiceRequest.locationReference Short description Requested location Definition A reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. Data type Reference(Location) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.actor rim: .participation[typeCode=LOC].role[scoper.determinerCode=INSTANCE]
reasonCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.reasonCode Short description Explanation/Justification for procedure or service Definition An explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use `CodeableConcept.text` element if the data is free (uncoded) text as shown in the CT Scan example. Data type CodeableConcept Binding Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.reasonCode w5: FiveWs.why[x] v2: ORC.16, RF1-10 rim: .reasonCode
reasonReference	Σ	0..*	Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference)	Element id ServiceRequest.reasonReference Short description Explanation/Justification for service or service Definition Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in `DiagnosticReport.conclusion` and/or `DiagnosticReport.conclusionCode`. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in `ServiceRequest.reasonCode` if the data is free (uncoded) text as shown in the CT Scan example. Data type Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference) Sliced: Unordered, Open, by $this.resolve()(Profile) Slice für referenzierten Histologiebefund oder bestimmten Tumorzellgehalt Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.reasonReference w5: FiveWs.why[x] v2: ORC.16 rim: .outboundRelationship[typeCode=RSON].target
Histologie	S Σ	0..1	Reference(MII_PR_Onko_Befund)	Element id ServiceRequest.reasonReference:Histologie Short description Histologiebefund Definition Verweis auf Histologiebefund Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in `DiagnosticReport.conclusion` and/or `DiagnosticReport.conclusionCode`. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in `ServiceRequest.reasonCode` if the data is free (uncoded) text as shown in the CT Scan example. Data type Reference(MII_PR_Onko_Befund) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.reasonReference w5: FiveWs.why[x] v2: ORC.16 rim: .outboundRelationship[typeCode=RSON].target
Tumorzellgehalt	S Σ	0..1	Reference(MII_PR_MTB_Tumorzellgehalt)	Element id ServiceRequest.reasonReference:Tumorzellgehalt Short description Tumorzellgehalt Definition Verweis auf bestimmten Tumorzellgehalt Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in `DiagnosticReport.conclusion` and/or `DiagnosticReport.conclusionCode`. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in `ServiceRequest.reasonCode` if the data is free (uncoded) text as shown in the CT Scan example. Data type Reference(MII_PR_MTB_Tumorzellgehalt) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.reasonReference w5: FiveWs.why[x] v2: ORC.16 rim: .outboundRelationship[typeCode=RSON].target
insurance		0..*	Reference(Coverage \| ClaimResponse)	There are no (further) constraints on this element Element id ServiceRequest.insurance Short description Associated insurance coverage Definition Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. Data type Reference(Coverage \| ClaimResponse) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.insurance v2: IN1/IN2 rim: .outboundRelationship[typeCode=COVBY].target
supportingInfo		0..*	Reference(Resource)	There are no (further) constraints on this element Element id ServiceRequest.supportingInfo Short description Additional clinical information Alternate names Ask at order entry question, AOE Definition Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. Comments To represent information about how the services are to be delivered use the `instructions` element. Data type Reference(Resource) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.supportingInfo v2: Accompanying segments rim: .outboundRelationship[typeCode=PERT].target
specimen	S Σ	0..*	Reference(MII_PR_Onko_Specimen \| MII_PR_Patho_Specimen \| ProfileSpecimenBioprobe \| Specimen)	Element id ServiceRequest.specimen Short description Procedure Samples Definition One or more specimens that the laboratory procedure will use. Comments Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest. Data type Reference(MII_PR_Onko_Specimen \| MII_PR_Patho_Specimen \| ProfileSpecimenBioprobe \| Specimen) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM rim: .participation[typeCode=SPC].role
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id ServiceRequest.bodySite Short description Location on Body Alternate names location Definition Anatomic location where the procedure should be performed. This is the target site. Requirements Knowing where the procedure is performed is important for tracking if multiple sites are possible. Comments Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM rim: targetSiteCode quick: Procedure.targetBodySite
note		0..*	Annotation	There are no (further) constraints on this element Element id ServiceRequest.note Short description Comments Definition Any other notes and comments made about the service request. For example, internal billing notes. Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.note v2: NTE rim: .inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST] quick: ClinicalStatement.additionalText
patientInstruction	Σ	0..1	string	There are no (further) constraints on this element Element id ServiceRequest.patientInstruction Short description Patient or consumer-oriented instructions Definition Instructions in terms that are understood by the patient or consumer. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: NTE rim: .text
relevantHistory		0..*	Reference(Provenance)	There are no (further) constraints on this element Element id ServiceRequest.relevantHistory Short description Request provenance Definition Key events in the history of the request. Comments This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject. Data type Reference(Provenance) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Request.relevantHistory v2: N/A rim: .inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]

Auftrag zur (erneuten) Histologie-Evaluation

Feldname	Kurzbeschreibung
ServiceRequest.meta
ServiceRequest.meta.profile
ServiceRequest.code	Empfehlung zur histologischen (Re-)Evaluation
ServiceRequest.reasonReference:Histologie	Histologiebefund
ServiceRequest.reasonReference:Tumorzellgehalt	Tumorzellgehalt
ServiceRequest.specimen

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-mtb-histologie-evaluation-auftrag" />
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-histologie-evaluation-auftrag" />
    <version value="2024.0.0-ballot" />
    <name value="MII_PR_MTB_Histologie_Evaluation_Auftrag" />
    <title value="MII PR MTB Histologie-Evaluation Auftrag" />
    <status value="draft" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Auftrag zur (erneuten) Histologie-Evaluation" />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="ServiceRequest" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/ServiceRequest" />
    <derivation value="constraint" />
    <differential>
        <element id="ServiceRequest.meta">
            <path value="ServiceRequest.meta" />
            <mustSupport value="true" />
        </element>
        <element id="ServiceRequest.meta.profile">
            <path value="ServiceRequest.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="ServiceRequest.status">
            <path value="ServiceRequest.status" />
            <definition value="Status der Umsetzung der Empfehlung" />
            <comment value="draft: Nicht umgesetzt, \n    active: In Umsetzung, \n    completed: Abgeschlossen oder abgebrochen (Patient verstorben)" />
        </element>
        <element id="ServiceRequest.code">
            <path value="ServiceRequest.code" />
            <short value="Empfehlung zur histologischen (Re-)Evaluation" />
            <definition value="Empfehlung zur histologischen (Re-)Evaluation" />
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="ServiceRequest.code.coding">
            <path value="ServiceRequest.code.coding" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
                <code value="183825009" />
                <display value="Refer for histology (procedure)" />
            </patternCoding>
        </element>
        <element id="ServiceRequest.reasonReference">
            <path value="ServiceRequest.reasonReference" />
            <slicing>
                <discriminator>
                    <type value="profile" />
                    <path value="$this.resolve()" />
                </discriminator>
                <description value="Slice f&#252;r referenzierten Histologiebefund oder bestimmten Tumorzellgehalt" />
                <ordered value="false" />
                <rules value="open" />
            </slicing>
        </element>
        <element id="ServiceRequest.reasonReference:Histologie">
            <path value="ServiceRequest.reasonReference" />
            <sliceName value="Histologie" />
            <short value="Histologiebefund" />
            <definition value="Verweis auf Histologiebefund" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ServiceRequest.reasonReference:Tumorzellgehalt">
            <path value="ServiceRequest.reasonReference" />
            <sliceName value="Tumorzellgehalt" />
            <short value="Tumorzellgehalt" />
            <definition value="Verweis auf bestimmten Tumorzellgehalt" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-tumorzellgehalt" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="ServiceRequest.specimen">
            <path value="ServiceRequest.specimen" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-specimen" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/StructureDefinition/Specimen" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Specimen" />
            </type>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-mtb-histologie-evaluation-auftrag",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-histologie-evaluation-auftrag",
    "version": "2024.0.0-ballot",
    "name": "MII_PR_MTB_Histologie_Evaluation_Auftrag",
    "title": "MII PR MTB Histologie-Evaluation Auftrag",
    "status": "draft",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Auftrag zur (erneuten) Histologie-Evaluation",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "ServiceRequest",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/ServiceRequest",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "ServiceRequest.meta",
                "path": "ServiceRequest.meta",
                "mustSupport": true
            },
            {
                "id": "ServiceRequest.meta.profile",
                "path": "ServiceRequest.meta.profile",
                "mustSupport": true
            },
            {
                "id": "ServiceRequest.status",
                "path": "ServiceRequest.status",
                "definition": "Status der Umsetzung der Empfehlung",
                "comment": "\n    draft: Nicht umgesetzt, \n    active: In Umsetzung, \n    completed: Abgeschlossen oder abgebrochen (Patient verstorben)"
            },
            {
                "id": "ServiceRequest.code",
                "path": "ServiceRequest.code",
                "short": "Empfehlung zur histologischen (Re-)Evaluation",
                "definition": "Empfehlung zur histologischen (Re-)Evaluation",
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "ServiceRequest.code.coding",
                "path": "ServiceRequest.code.coding",
                "patternCoding": {
                    "code": "183825009",
                    "system": "http://snomed.info/sct",
                    "display": "Refer for histology (procedure)"
                }
            },
            {
                "id": "ServiceRequest.reasonReference",
                "path": "ServiceRequest.reasonReference",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "profile",
                            "path": "$this.resolve()"
                        }
                    ],
                    "rules": "open",
                    "description": "Slice für referenzierten Histologiebefund oder bestimmten Tumorzellgehalt",
                    "ordered": false
                }
            },
            {
                "id": "ServiceRequest.reasonReference:Histologie",
                "path": "ServiceRequest.reasonReference",
                "sliceName": "Histologie",
                "short": "Histologiebefund",
                "definition": "Verweis auf Histologiebefund",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ServiceRequest.reasonReference:Tumorzellgehalt",
                "path": "ServiceRequest.reasonReference",
                "sliceName": "Tumorzellgehalt",
                "short": "Tumorzellgehalt",
                "definition": "Verweis auf bestimmten Tumorzellgehalt",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-tumorzellgehalt"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "ServiceRequest.specimen",
                "path": "ServiceRequest.specimen",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen",
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-specimen",
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/StructureDefinition/Specimen",
                            "http://hl7.org/fhir/StructureDefinition/Specimen"
                        ]
                    }
                ],
                "mustSupport": true
            }
        ]
    }
}

MII PR MTB Histologie-Evaluation Auftrag

Mapping Datensatz zu FHIR

Datensatz	Erklaerung	FHIR
Auftrag zur Histologie-Reevaluation	Auftrag zur Histologie-Reevaluation gemäß Beschluss des Molekularen Tumorboards	ServiceRequest
Verweis auf Probe	Verweis auf entnommene Probe	ServiceRequest.specimen:Reference(Specimen)
Verweis auf Histologiebefund	Verweis auf den Befund zur Histologie des Tumors	ServiceRequest.reasonReference:Reference(DiagnosticReport)

Suchparameter

Folgende Suchparameter sind für dieses Modul relevant, auch in Kombination:

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?_id=12345

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]/ServiceRequest?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-biopsie-auftrag

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]/ServiceRequest?code=http://snomed.info/sct|183825009

Anwendungshinweise: Weitere Informationen zur Suche nach "code" finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search"
Der Suchparameter "reason-reference" MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?reason-reference=Observation/example

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

Beispiele:

GET [base]/ServiceRequest?specimen=Specimen/example

Anwendungshinweise: Weitere Informationen zur Suche nach "specimen" finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search"

Beispiele

Beispiel: Auftrag zur histologischen Evaluation für Kim Musterperson vom 28.03.2023 (siehe Beschreibung von Szenarien fuer die Anwendung der Module)

Tabelle
JSON

ServiceRequest.id[0]	mii-exa-mtb-kim-histologie-evaluation-aszites
ServiceRequest.meta[0].profile[0]	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-histologie-evaluation-auftrag
ServiceRequest.status[0]	draft
ServiceRequest.intent[0]	proposal
ServiceRequest.code[0].coding[0].system[0]	http://snomed.info/sct
ServiceRequest.code[0].coding[0].code[0]	183825009
ServiceRequest.code[0].coding[0].display[0]	Refer for histology (procedure)
ServiceRequest.subject[0].reference[0]	Patient/PatientKimMusterperson
ServiceRequest.reasonReference[0].reference[0]	Observation/mii-exa-mtb-kim-tumorzellgehalt-aszites
ServiceRequest.specimen[0].reference[0]	Specimen/PatientKimMusterperson-AscitesSpecimen-2

{
    "resourceType": "ServiceRequest",
    "id": "mii-exa-mtb-kim-histologie-evaluation-aszites",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-histologie-evaluation-auftrag"
        ]
    },
    "code": {
        "coding":  [
            {
                "code": "183825009",
                "system": "http://snomed.info/sct",
                "display": "Refer for histology (procedure)"
            }
        ]
    },
    "reasonReference":  [
        {
            "reference": "Observation/mii-exa-mtb-kim-tumorzellgehalt-aszites"
        }
    ],
    "specimen":  [
        {
            "reference": "Specimen/PatientKimMusterperson-AscitesSpecimen-2"
        }
    ],
    "status": "draft",
    "intent": "proposal",
    "subject": {
        "reference": "Patient/PatientKimMusterperson"
    }
}