Histologiebefund: DiagnosticReport

This profile describes a pathology report in oncology.

Since the data comes from local tumor documentation systems, most of the findings will be in pure text form.

The pathology report CAN also be done via the pathology report within the MII. In this case, individual observations can be structured and coded as Patho Findings using LOINC or SNOMED. 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

Content

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.

Query syntax is not valid. Location: select Field |Name: id, Short Description: short, Notes: comment
<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 dataset to FHIR

DatasetExplanationFHIR
Befund

Vollständiger Befundbericht des Pathologen.

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

Mapping Unified Oncological Basic Dataset (oBDS) to FHIR

oBDSDefinitionFHIR
6.11BefundDiagnosticReport.conclusion

Search Parameters

The following search parameters are relevant for the oncology module, also in combination:

  1. The search parameter _id MUST be supported:

    Examples:

    GET [base]/Condition?_id=1234

    Application notes: Further information on searching by "_id" can be found in the FHIR base specification - section "Parameters for all resources".

  2. The search parameter "_profile" MUST be supported:

    Examples:

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

    Application notes: Further information on searching by "_profile" can be found in the FHIR base specification - section "token".

Examples

{
"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, ..."
}