Histologiebefund: DiagnosticReport

Dieses Profil beschreibt einen Pathologie-Befund im Rahmen in der Onkologie.

Da die Daten aus den lokalen Tumordokumentationssystemen stammen, wird ein Großteil der Befunde in reiner Textform vorliegen.

Die Pathologie-Befundung KANN im Rahmen der MII ebenfalls über den Pathologie-Befundbericht erfolgen. In dem Fall können einzelne Beobachtung als Patho Findings über LOINC oder SNOMED strukturiert codiert werden. https://www.medizininformatik-initiative.de/Kerndatensatz/Modul_Pathologie_Befund/MII-IG-KDS-Modul-Pathologie-Befund-TechnischeImplementierung-FHIRProfile-MII-PR-Patho-Report.html

NameStatusVersionCanonicalBasis
MII_PR_Onko_Befundactive2025.1.0https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befundhttp://hl7.org/fhir/StructureDefinition/DiagnosticReport

Inhalt

idΣ0..1string
id0..1string
extensionC0..*Extension
versionIdΣ0..1id
lastUpdatedΣ0..1instant
sourceΣ0..1uri
profileS Σ0..*canonical(StructureDefinition)
securityΣ0..*CodingBinding
tagΣ0..*Coding
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
extensionC0..*Extension
modifierExtension?! C0..*Extension
identifierΣ0..*Identifier
tumorkonferenzS0..1Reference(MII_PR_Onko_Tumorkonferenz)
statusΣ ?!1..1codeBinding
categoryΣ0..*CodeableConcept
id0..1string
extensionC0..*Extension
id0..1string
extensionC0..*Extension
systemS Σ1..1uriPattern
versionΣ0..1string
codeS Σ1..1codePattern
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
subjectS Σ1..1Reference(Patient)
encounterS Σ0..1Reference(Encounter)
effectiveDateTimedateTime
effectivePeriodPeriod
issuedΣ0..1instant
performerΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
resultsInterpreterΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)
specimenS0..*Reference(MII_PR_Onko_Specimen | Specimen)
result0..*Reference(Observation)
imagingStudy0..*Reference(ImagingStudy)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
comment0..1string
conclusionS1..1string
conclusionCode0..*CodeableConcept
presentedForm0..*Attachment

Histologie: Befund. Vollständiger Befundbericht des Pathologen.

FeldnameKurzbeschreibung
DiagnosticReport.meta.profile
DiagnosticReport.basedOn
DiagnosticReport.basedOn:tumorkonferenz
DiagnosticReport.codePathology report code
DiagnosticReport.code.coding
DiagnosticReport.code.coding:pathology-report
DiagnosticReport.code.coding:pathology-report.system
DiagnosticReport.code.coding:pathology-report.code
DiagnosticReport.subject
DiagnosticReport.encounter
DiagnosticReport.specimen
DiagnosticReport.conclusionBefund als Freitext
<StructureDefinition xmlns="http://hl7.org/fhir">
<id value="mii-pr-onko-befund" />
<url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund" />
<version value="2025.1.0" />
<name value="MII_PR_Onko_Befund" />
<title value="MII PR Onkologie Befund" />
<status value="active" />
<publisher value="Medizininformatik Initiative" />
<system value="url" />
<value value="https://www.medizininformatik-initiative.de" />
</telecom>
</contact>
<description value="Histologie: Befund. Vollständiger Befundbericht des Pathologen." />
<fhirVersion value="4.0.1" />
<identity value="oBDS" />
<name value="Mapping FHIR zu oBDS" />
</mapping>
<kind value="resource" />
<abstract value="false" />
<type value="DiagnosticReport" />
<baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
<derivation value="constraint" />
<element id="DiagnosticReport.meta.profile">
<path value="DiagnosticReport.meta.profile" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.basedOn">
<path value="DiagnosticReport.basedOn" />
<type value="type" />
<path value="$this.resolve()" />
</discriminator>
<rules value="open" />
</slicing>
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.basedOn:tumorkonferenz">
<path value="DiagnosticReport.basedOn" />
<sliceName value="tumorkonferenz" />
<min value="0" />
<max value="1" />
<code value="Reference" />
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz" />
</type>
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.code">
<path value="DiagnosticReport.code" />
<short value="Pathology report code" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.code.coding">
<path value="DiagnosticReport.code.coding" />
<type value="pattern" />
<path value="$this" />
</discriminator>
<rules value="open" />
</slicing>
<min value="1" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.code.coding:pathology-report">
<path value="DiagnosticReport.code.coding" />
<sliceName value="pathology-report" />
<min value="1" />
<max value="1" />
<system value="http://loinc.org" />
<code value="22034-3" />
</patternCoding>
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.code.coding:pathology-report.system">
<path value="DiagnosticReport.code.coding.system" />
<min value="1" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.code.coding:pathology-report.code">
<path value="DiagnosticReport.code.coding.code" />
<min value="1" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.subject">
<path value="DiagnosticReport.subject" />
<min value="1" />
<code value="Reference" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
</type>
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.encounter">
<path value="DiagnosticReport.encounter" />
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.specimen">
<path value="DiagnosticReport.specimen" />
<code value="Reference" />
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen" />
<targetProfile value="http://hl7.org/fhir/StructureDefinition/Specimen" />
</type>
<mustSupport value="true" />
</element>
<element id="DiagnosticReport.conclusion">
<path value="DiagnosticReport.conclusion" />
<short value="Befund als Freitext">
<extension url="http://hl7.org/fhir/StructureDefinition/translation">
<extension url="lang">
<valueCode value="de-DE" />
</extension>
<extension url="content">
<valueString value="Befund als Freitext" />
</extension>
</extension>
</short>
<definition value="Befund als Freitext nach 6.11 oBDS 2021">
<extension url="http://hl7.org/fhir/StructureDefinition/translation">
<extension url="lang">
<valueCode value="de-DE" />
</extension>
<extension url="content">
<valueString value="Befund als Freitext nach 6.11 oBDS 2021" />
</extension>
</extension>
</definition>
<min value="1" />
<mustSupport value="true" />
<identity value="oBDS" />
<map value="6.11" />
<comment value="Befund" />
</mapping>
</element>
</differential>
</StructureDefinition>
{
"resourceType": "StructureDefinition",
"id": "mii-pr-onko-befund",
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund",
"version": "2025.1.0",
"name": "MII_PR_Onko_Befund",
"title": "MII PR Onkologie Befund",
"status": "active",
"publisher": "Medizininformatik Initiative",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "https://www.medizininformatik-initiative.de"
}
]
}
],
"description": "Histologie: Befund. Vollständiger Befundbericht des Pathologen.",
"fhirVersion": "4.0.1",
"mapping": [
{
"identity": "oBDS",
"name": "Mapping FHIR zu oBDS"
}
],
"kind": "resource",
"abstract": false,
"type": "DiagnosticReport",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
"derivation": "constraint",
"element": [
{
"id": "DiagnosticReport.meta.profile",
"path": "DiagnosticReport.meta.profile",
"mustSupport": true
},
{
"id": "DiagnosticReport.basedOn",
"path": "DiagnosticReport.basedOn",
"slicing": {
{
"type": "type",
"path": "$this.resolve()"
}
],
"rules": "open"
},
"mustSupport": true
},
{
"id": "DiagnosticReport.basedOn:tumorkonferenz",
"path": "DiagnosticReport.basedOn",
"sliceName": "tumorkonferenz",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz"
]
}
],
"mustSupport": true
},
{
"id": "DiagnosticReport.code",
"path": "DiagnosticReport.code",
"short": "Pathology report code",
"mustSupport": true
},
{
"id": "DiagnosticReport.code.coding",
"path": "DiagnosticReport.code.coding",
"slicing": {
{
"type": "pattern",
"path": "$this"
}
],
"rules": "open"
},
"min": 1,
"mustSupport": true
},
{
"id": "DiagnosticReport.code.coding:pathology-report",
"path": "DiagnosticReport.code.coding",
"sliceName": "pathology-report",
"min": 1,
"max": "1",
"code": "22034-3",
"system": "http://loinc.org"
},
"mustSupport": true
},
{
"id": "DiagnosticReport.code.coding:pathology-report.system",
"path": "DiagnosticReport.code.coding.system",
"min": 1,
"mustSupport": true
},
{
"id": "DiagnosticReport.code.coding:pathology-report.code",
"path": "DiagnosticReport.code.coding.code",
"min": 1,
"mustSupport": true
},
{
"id": "DiagnosticReport.subject",
"path": "DiagnosticReport.subject",
"min": 1,
"type": [
{
"code": "Reference",
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"mustSupport": true
},
{
"id": "DiagnosticReport.encounter",
"path": "DiagnosticReport.encounter",
"mustSupport": true
},
{
"id": "DiagnosticReport.specimen",
"path": "DiagnosticReport.specimen",
"type": [
{
"code": "Reference",
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen",
"http://hl7.org/fhir/StructureDefinition/Specimen"
]
}
],
"mustSupport": true
},
{
"id": "DiagnosticReport.conclusion",
"path": "DiagnosticReport.conclusion",
"short": "Befund als Freitext",
"_short": {
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
{
"url": "lang",
"valueCode": "de-DE"
},
{
"url": "content",
"valueString": "Befund als Freitext"
}
]
}
]
},
"definition": "Befund als Freitext nach 6.11 oBDS 2021",
{
"url": "http://hl7.org/fhir/StructureDefinition/translation",
{
"url": "lang",
"valueCode": "de-DE"
},
{
"url": "content",
"valueString": "Befund als Freitext nach 6.11 oBDS 2021"
}
]
}
]
},
"min": 1,
"mustSupport": true,
"mapping": [
{
"identity": "oBDS",
"map": "6.11",
"comment": "Befund"
}
]
}
]
}
}

Mapping Datensatz zu FHIR

DatensatzErklaerungFHIR
Befund

Vollständiger Befundbericht des Pathologen.

DiagnosticReport.code.coding.where(system='http://loinc.org' and code='60568-3').select(%resource.conclusion)

Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) zu FHIR

oBDSDefinitionFHIR
6.11BefundDiagnosticReport.conclusion

Suchparameter

Folgende Suchparameter sind für das Modul Onkologie relevant, auch in Kombination:

  1. Der Suchparameter _id MUSS unterstützt werden:

    Beispiele:

    GET [base]/Condition?_id=1234

    Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".

  2. Der Suchparameter "_profile" MUSS unterstützt werden:

    Beispiele:

    GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund

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

Beispiele

{
"resourceType": "DiagnosticReport",
"id": "mii-exa-onko-befund-1",
"meta": {
"profile": [
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund"
]
},
"code": {
"coding": [
{
"code": "22034-3",
"system": "http://loinc.org"
}
]
},
"status": "final",
"subject": {
"reference": "Patient/PatientKimMusterperson"
},
"basedOn": [
{
"reference": "CarePlan/example-tumorboard-1"
}
],
{
"reference": "Specimen/example-specimen-2"
}
],
"conclusion": "Mäßig differenziertes invasiv duktales Karzinom (8500/3), Grading G2 an der rechten Mamma, ..."
}