MII IG Befunde bildgebender Verfahren DE v2025

DiagnosticReport

Der Diagnostic Report für Bildgebende verfahren richtet sich an die Dokumentation von radiologischen Befundungsergebnissen. Unterschiedliche Systeme (RIS Befundungsmodule, AI Integrationen dedizierte Systeme zur strukturieren Befundung) lieferen in unterschiedlichem Detailgrad Informationen. Dieses Profil addressiert diese unterschiedlichen Detailgrade und bietet modulare aufeinander aufbauende Stufen. Jede Stufe fügt weitere Konzepte hinzu und ermöglicht so neue Anwendungsmöglichkeiten von der Routine bis hin zu wissenschaftlichen Auswertungen.

Stufe 1 - Freitext in strukturierter Form
Auf der grundlegendsten Ebene ermöglicht die DiagnosticReport-Ressource die Einbindung von radiologischen Befunden als Freitext in einer strukturierten Form. Dies erlaubt eine einfache, jedoch effektive Darstellung von diagnostischen Informationen. Die Freitextbeschreibung bietet die Möglichkeit, ohne komplexen Datenaustausch, essenzielle Befundinformationen zu übermitteln.

Stufe 2 - Verlinkung von Observation-Ressourcen
Auf der nächsten Stufe werden DiagnosticReport-Ressourcen mit Observation-Ressourcen verknüpft. Dies erlaubt eine detailliertere Erfassung und Darstellung spezifischer Befunde oder Messwerte. Da diese Ressourcen maschinenlesbar und auch kodiert sind ist es möglich nach diesen Inhalten zu suchen sie für Auswertungen zu verwenden oder auch Workflows zu steuern.

Stufe 3 - Bezugnahme auf anatomische Strukturen
Die Verknüpfung mit BodyStructure-Ressourcen stellt eine Erweiterung dar, die es ermöglicht, Observations präzise anatomischen Strukturen zuzuordnen. Dieser Bezug ist insbesondere für die longitudinale Patientenversorgung von Bedeutung, da er die Verfolgung und Bezugnahme auf spezifische Läsionen oder Anomalien in Folgeuntersuchungen oder in anderen klinischen Kontexten, wie beispielsweise in der Pathologie, ermöglicht. Wichtig dabei ist, dass die BodyStructure Ressource nicht Teil des Diagnostic Reports ist. Somit müssen Observations auf diese Ressource versioniert verweisen.

Stufe 4 - Einführung von Befundungs Prozeduren
Die Integration von Procedure-Ressourcen bietet einen weiteren Detaillierungsgrad, indem sie den Kontext / die Bedingungen beschreibt, unter denen die Observations erhoben wurden. Dies erlaubt eine tiefere Einsicht in die Umstände der Befundung, indem klar definiert wird, nach welchen Kriterien und Voraussetzungen spezifische Informationen und Messwerte erfasst wurden. Die Verknüpfung mit Procedure-Ressourcen erweitert somit den diagnostischen Bericht um wichtige kontextuelle Informationen, die für die Interpretation der Befunde entscheidend sein können.

Name	Status	Version	Canonical	Basis
MII_PR_Bildgebung_Radiologischer_Befund	active	2025.0.0	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund	http://hl7.org/fhir/StructureDefinition/DiagnosticReport

Inhalt

MII_PR_Bildgebung_Radiologischer_Befund (DiagnosticReport)	I		DiagnosticReport	There are no (further) constraints on this element 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 DiagnosticReport 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]
id	S Σ	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	S Σ	0..1	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 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
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.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 DiagnosticReport.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 rim: N/A
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id DiagnosticReport.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())` Mappings rim: n/a
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id DiagnosticReport.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())` Mappings rim: n/a
source	S Σ	0..1	uri	There are no (further) constraints on this element Element id DiagnosticReport.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())` Mappings rim: n/a
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id DiagnosticReport.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())` Mappings rim: n/a
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id DiagnosticReport.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())` 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
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id DiagnosticReport.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())` 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
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 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) 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 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	I	0..*	Extension	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 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 rim: N/A
supportingInfo	S I	0..*	Extension	Element id DiagnosticReport.extension:supportingInfo Short description Zusatzinformation Alternate names extensions, user content Definition Zusatzinformation zum Befundbericht 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 Extension URL http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo 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 DiagnosticReport.extension:supportingInfo.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 DiagnosticReport.extension:supportingInfo.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 rim: N/A
type	S I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.extension:type 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 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
reference	S I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.extension:reference 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 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 DiagnosticReport.extension:supportingInfo.extension:reference.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 DiagnosticReport.extension:supportingInfo.extension:reference.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 rim: N/A
url		1..1	uriFixed Value	There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.extension:reference.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 reference Mappings rim: N/A
value[x]		0..1		There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.extension:reference.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). 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(DiagnosticReport \| Procedure)	Data type Reference(DiagnosticReport \| Procedure)
url		1..1	uriFixed Value	There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.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/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo Mappings rim: N/A
value[x]		0..1		There are no (further) constraints on this element Element id DiagnosticReport.extension:supportingInfo.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). 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
valueBase64Binary			base64Binary	There are no (further) constraints on this element Data type base64Binary
valueBoolean			boolean	There are no (further) constraints on this element Data type boolean
valueCanonical			canonical()	There are no (further) constraints on this element Data type canonical()
valueCode			code	There are no (further) constraints on this element Data type code
valueDate			date	There are no (further) constraints on this element Data type date
valueDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
valueDecimal			decimal	There are no (further) constraints on this element Data type decimal
valueId			id	There are no (further) constraints on this element Data type id
valueInstant			instant	There are no (further) constraints on this element Data type instant
valueInteger			integer	There are no (further) constraints on this element Data type integer
valueMarkdown			markdown	There are no (further) constraints on this element Data type markdown
valueOid			oid	There are no (further) constraints on this element Data type oid
valuePositiveInt			positiveInt	There are no (further) constraints on this element Data type positiveInt
valueString			string	There are no (further) constraints on this element Data type string
valueTime			time	There are no (further) constraints on this element Data type time
valueUnsignedInt			unsignedInt	There are no (further) constraints on this element Data type unsignedInt
valueUri			uri	There are no (further) constraints on this element Data type uri
valueUrl			url	There are no (further) constraints on this element Data type url
valueUuid			uuid	There are no (further) constraints on this element Data type uuid
valueAddress			Address	There are no (further) constraints on this element Data type Address
valueAge			Age	There are no (further) constraints on this element Data type Age
valueAnnotation			Annotation	There are no (further) constraints on this element Data type Annotation
valueAttachment			Attachment	There are no (further) constraints on this element Data type Attachment
valueCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
valueCoding			Coding	There are no (further) constraints on this element Data type Coding
valueContactPoint			ContactPoint	There are no (further) constraints on this element Data type ContactPoint
valueCount			Count	There are no (further) constraints on this element Data type Count
valueDistance			Distance	There are no (further) constraints on this element Data type Distance
valueDuration			Duration	There are no (further) constraints on this element Data type Duration
valueHumanName			HumanName	There are no (further) constraints on this element Data type HumanName
valueIdentifier			Identifier	There are no (further) constraints on this element Data type Identifier
valueMoney			Money	There are no (further) constraints on this element Data type Money
valuePeriod			Period	There are no (further) constraints on this element Data type Period
valueQuantity			Quantity	There are no (further) constraints on this element Data type Quantity
valueRange			Range	There are no (further) constraints on this element Data type Range
valueRatio			Ratio	There are no (further) constraints on this element Data type Ratio
valueSampledData			SampledData	There are no (further) constraints on this element Data type SampledData
valueSignature			Signature	There are no (further) constraints on this element Data type Signature
valueTiming			Timing	There are no (further) constraints on this element Data type Timing
valueContactDetail			ContactDetail	There are no (further) constraints on this element Data type ContactDetail
valueContributor			Contributor	There are no (further) constraints on this element Data type Contributor
valueDataRequirement			DataRequirement	There are no (further) constraints on this element Data type DataRequirement
valueExpression			Expression	There are no (further) constraints on this element Data type Expression
valueParameterDefinition			ParameterDefinition	There are no (further) constraints on this element Data type ParameterDefinition
valueRelatedArtifact			RelatedArtifact	There are no (further) constraints on this element Data type RelatedArtifact
valueTriggerDefinition			TriggerDefinition	There are no (further) constraints on this element Data type TriggerDefinition
valueUsageContext			UsageContext	There are no (further) constraints on this element Data type UsageContext
valueDosage			Dosage	There are no (further) constraints on this element Data type Dosage
valueMeta			Meta	There are no (further) constraints on this element Data type Meta
valueReference			Reference()	There are no (further) constraints on this element Data type Reference()
modifierExtension	?! I	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 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 rim: N/A
identifier	Σ	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 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	S I	0..*	Reference(MII_PR_Bildgebung_Anforderung_Bildgebung \| CarePlan)	Element id DiagnosticReport.basedOn Short description Anforderung Alternate names Request Definition Anforderung, die den Befundbericht ausgelöst hat 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(MII_PR_Bildgebung_Anforderung_Bildgebung \| CarePlan) 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 Definition angemeldet \| unvollständig \| vorläufig \| endgültig \| geändert \| korrigiert \| angefügt \| abgebrochen \| fehlerhafte Eingabe \| unbekannt 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) 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"
category	S Σ	1..*	CodeableConcept	Element id DiagnosticReport.category Short description Kategorie Alternate names Department, Sub-department, Service, Discipline Definition Kategorie des Befundberichts 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 Binding Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) 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
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.category.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 DiagnosticReport.category.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 rim: N/A
coding	S Σ	1..*	Coding	Element id DiagnosticReport.category.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 Sliced: Unordered, Open, by $this(Pattern) 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 subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
loinc	S Σ	0..*	CodingPattern	Element id DiagnosticReport.category.coding:loinc 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://loinc.org", "code": "18748-4" } 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: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
diagnostic-service-sections	S Σ	0..*	CodingPattern	Element id DiagnosticReport.category.coding:diagnostic-service-sections 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://terminology.hl7.org/CodeSystem/v2-0074", "code": "RAD" } 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: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
sct	S Σ	1..1	CodingPattern	Element id DiagnosticReport.category.coding:sct 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": "4201000179104" } 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: 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 DiagnosticReport.category.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 rim: n/a 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
code	S Σ	1..1	CodeableConceptBinding	Element id DiagnosticReport.code Short description Code Alternate names Type Definition Code des Befundberichts 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) 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 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
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.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 DiagnosticReport.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 rim: N/A
coding	Σ	0..*	Coding	Element id DiagnosticReport.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 Sliced: Unordered, Open, by $this(Pattern) 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 subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
sct	S Σ	0..1	CodingPattern	Element id DiagnosticReport.code.coding:sct 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" } 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: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
loinc	S Σ	0..1	CodingPattern	Element id DiagnosticReport.code.coding:loinc 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://loinc.org" } 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: 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 DiagnosticReport.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 rim: n/a 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
subject	S Σ I	1..1	Reference(Patient)	Element id DiagnosticReport.subject Short description Person Alternate names Patient Definition Person, auf die sich die 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(Patient) 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 I	0..1	Reference(Encounter)	Element id DiagnosticReport.encounter Short description Versorgungssstellenkontakt Alternate names Context Definition Fall-Referenz auf den Versorgungssstellenkontakt 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) 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]	S Σ	0..1		Element id DiagnosticReport.effective[x] Short description Erstellungsdatum Alternate names Observation time, Effective Time, Occurrence Definition Zeitpunkt der Erstellung 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. Sliced: Unordered, Open, by $this(Type) 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	S Σ	0..1	dateTime	Element id DiagnosticReport.effective[x]:effectiveDateTime 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. Data type dateTime 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
effectivePeriod	S Σ	0..1	Period	Element id DiagnosticReport.effective[x]:effectivePeriod 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. Data type Period 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
issued	S Σ	0..1	instant	Element id DiagnosticReport.issued Short description Erstellungszeitpunkt Alternate names Date published, Date Issued, Date Verified Definition Zeit an der der Bericht erstellt wurde 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 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
performer	Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	There are no (further) constraints on this element Element id DiagnosticReport.performer Short description Responsible Diagnostic Service Alternate names Laboratory, Service, Practitioner, Department, Company, Authorized by, Director Definition The diagnostic service that is responsible for issuing the report. 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(Practitioner \| PractitionerRole \| Organization \| CareTeam) 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]
resultsInterpreter	Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	There are no (further) constraints on this element Element id DiagnosticReport.resultsInterpreter Short description Primary result interpreter Alternate names Analyzed by, Reported by Definition The practitioner or organization that is responsible for the report's conclusions and interpretations. 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(Practitioner \| PractitionerRole \| Organization \| CareTeam) 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]
specimen	I	0..*	Reference(Specimen)	There are no (further) constraints on this element Element id DiagnosticReport.specimen Short description Specimens this report is based on Definition Details about the specimens on which this diagnostic report is based. 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) 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 I	0..*	Reference(Observation)	Element id DiagnosticReport.result Short description Ergebnis Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Ergebnis einer Beobachtung 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) 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	S I	1..*	Reference(MII_PR_Bildgebung_Bildgebungsstudie)	Element id DiagnosticReport.imagingStudy Short description Bildgebungsstudie Definition Studie, die die vollständige Bildgebung umfasst 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(MII_PR_Bildgebung_Bildgebungsstudie) 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	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element id DiagnosticReport.media Short description Key images associated with this report Alternate names DICOM, Slides, Scans Definition A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Requirements Many diagnostic services include images in the report as part of their service. Data type BackboneElement 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
id		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	I	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 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 rim: N/A
modifierExtension	Σ ?! I	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 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 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 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 I	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 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(Media) 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	S	0..1	string	Element id DiagnosticReport.conclusion Short description Fazit Alternate names Report Definition Fazit zur aktuellen Befundung 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 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	S	0..*	CodeableConcept	Element id DiagnosticReport.conclusionCode Short description Strukturiertes Fazit Definition Fazit, welches strukturiert über Codes dargestellt wird 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 Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) 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)
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.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 DiagnosticReport.conclusionCode.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 rim: N/A
coding	S Σ	0..*	Coding	Element id DiagnosticReport.conclusionCode.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 Sliced: Unordered, Open, by $this(Pattern) 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 subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
icd10-gm	S Σ	0..*	CodingPattern	Element id DiagnosticReport.conclusionCode.coding:icd10-gm 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://fhir.de/CodeSystem/bfarm/icd-10-gm" } 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: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
sct	S Σ	0..*	CodingPattern	Element id DiagnosticReport.conclusionCode.coding:sct 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" } 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: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.coding:sct.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 DiagnosticReport.conclusionCode.coding:sct.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 rim: N/A
system	Σ	0..1	uriPattern	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.coding:sct.system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://snomed.info/sct Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.coding:sct.version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	0..1	codeBinding	Element id DiagnosticReport.conclusionCode.coding:sct.code Short description Symbol in syntax defined by the system Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Binding MII_VS_Bildgebung_Diagnostic_Report_Coding (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.coding:sct.display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.coding:sct.userSelected Short description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). Requirements This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Comments Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: Sometimes implied by being first rim: CD.codingRationale orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
text	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode.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 rim: n/a 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
presentedForm	S I	0..*	Attachment	Element id DiagnosticReport.presentedForm Short description Anhang Definition zusätzlicher wichtiger Anhang 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 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)

Diese Ressource beschreibt einen radiologischen Befund

Feldname	Kurzbeschreibung
DiagnosticReport.id
DiagnosticReport.meta
DiagnosticReport.meta.source
DiagnosticReport.meta.profile
DiagnosticReport.extension:supportingInfo	Zusatzinformation
DiagnosticReport.extension:supportingInfo.extension:type
DiagnosticReport.extension:supportingInfo.extension:reference
DiagnosticReport.basedOn	Anforderung
DiagnosticReport.status	Status
DiagnosticReport.category	Kategorie
DiagnosticReport.category.coding
DiagnosticReport.category.coding:loinc
DiagnosticReport.category.coding:diagnostic-service-sections
DiagnosticReport.category.coding:sct
DiagnosticReport.code	Code
DiagnosticReport.code.coding:sct
DiagnosticReport.code.coding:loinc
DiagnosticReport.subject	Person
DiagnosticReport.encounter	Versorgungssstellenkontakt
DiagnosticReport.effective[x]	Erstellungsdatum
DiagnosticReport.effective[x]:effectiveDateTime
DiagnosticReport.effective[x]:effectivePeriod
DiagnosticReport.issued	Erstellungszeitpunkt
DiagnosticReport.result	Ergebnis
DiagnosticReport.imagingStudy	Bildgebungsstudie
DiagnosticReport.conclusion	Fazit
DiagnosticReport.conclusionCode	Strukturiertes Fazit
DiagnosticReport.conclusionCode.coding
DiagnosticReport.conclusionCode.coding:icd10-gm
DiagnosticReport.conclusionCode.coding:sct
DiagnosticReport.presentedForm	Anhang

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-bildgebung-radiologischer-befund" />
    <extension url="https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-ex-meta-license-codeable">
        <valueCodeableConcept>
            <coding>
                <system value="http://hl7.org/fhir/spdx-license" />
                <code value="CC-BY-4.0" />
                <display value="Creative Commons Attribution 4.0 International" />
            </coding>
        </valueCodeableConcept>
    </extension>
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund" />
    <version value="2025.0.0" />
    <name value="MII_PR_Bildgebung_Radiologischer_Befund">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII_PR_Imaging_Diagnostic_Report" />
            </extension>
        </extension>
    </name>
    <title value="MII PR Bildgebung Radiologischer Befund">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII PR Imaging Diagnostic Report" />
            </extension>
        </extension>
    </title>
    <status value="active" />
    <date value="2025-01-01" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Diese Ressource beschreibt einen radiologischen Befund">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="The profile describes a diagnostic report for a radiological image." />
            </extension>
        </extension>
    </description>
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="DiagnosticReport" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
    <derivation value="constraint" />
    <differential>
        <element id="DiagnosticReport.id">
            <path value="DiagnosticReport.id" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.meta">
            <path value="DiagnosticReport.meta" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.meta.source">
            <path value="DiagnosticReport.meta.source" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.meta.profile">
            <path value="DiagnosticReport.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.extension">
            <path value="DiagnosticReport.extension" />
            <slicing>
                <discriminator>
                    <type value="value" />
                    <path value="url" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
        </element>
        <element id="DiagnosticReport.extension:supportingInfo">
            <path value="DiagnosticReport.extension" />
            <sliceName value="supportingInfo" />
            <short value="Zusatzinformation">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Zusatzinformation" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="additional information" />
                    </extension>
                </extension>
            </short>
            <definition value="Zusatzinformation zum Befundbericht">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Zusatzinformation zum Befundbericht" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="additional information for the report" />
                    </extension>
                </extension>
            </definition>
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Extension" />
                <profile value="http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.extension:supportingInfo.extension:type">
            <path value="DiagnosticReport.extension.extension" />
            <sliceName value="type" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.extension:supportingInfo.extension:reference">
            <path value="DiagnosticReport.extension.extension" />
            <sliceName value="reference" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.extension:supportingInfo.extension:reference.value[x]">
            <path value="DiagnosticReport.extension.extension.value[x]" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Procedure" />
            </type>
        </element>
        <element id="DiagnosticReport.basedOn">
            <path value="DiagnosticReport.basedOn" />
            <short value="Anforderung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Anforderung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="request" />
                    </extension>
                </extension>
            </short>
            <definition value="Anforderung, die den Befundbericht ausgel&#246;st hat">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Anforderung, die den Befundbericht ausgel&#246;st hat" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="request, which triggered the report" />
                    </extension>
                </extension>
            </definition>
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-anforderung-bildgebung" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/CarePlan" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.status">
            <path value="DiagnosticReport.status" />
            <short value="Status">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Status" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="status" />
                    </extension>
                </extension>
            </short>
            <definition value="angemeldet | unvollst&#228;ndig | vorl&#228;ufig | endg&#252;ltig | ge&#228;ndert | korrigiert | angef&#252;gt | abgebrochen | fehlerhafte Eingabe | unbekannt">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="angemeldet | unvollst&#228;ndig | vorl&#228;ufig | endg&#252;ltig | ge&#228;ndert | korrigiert | angef&#252;gt | abgebrochen | fehlerhafte Eingabe | unbekannt" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.category">
            <path value="DiagnosticReport.category" />
            <short value="Kategorie">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Kategorie" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="category" />
                    </extension>
                </extension>
            </short>
            <definition value="Kategorie des Befundberichts">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Kategorie des Befundberichts" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="category of the diagnostic report" />
                    </extension>
                </extension>
            </definition>
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.category.coding">
            <path value="DiagnosticReport.category.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <min value="1" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.category.coding:loinc">
            <path value="DiagnosticReport.category.coding" />
            <sliceName value="loinc" />
            <min value="0" />
            <max value="*" />
            <patternCoding>
                <system value="http://loinc.org" />
                <code value="18748-4" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.category.coding:diagnostic-service-sections">
            <path value="DiagnosticReport.category.coding" />
            <sliceName value="diagnostic-service-sections" />
            <min value="0" />
            <max value="*" />
            <patternCoding>
                <system value="http://terminology.hl7.org/CodeSystem/v2-0074" />
                <code value="RAD" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.category.coding:sct">
            <path value="DiagnosticReport.category.coding" />
            <sliceName value="sct" />
            <min value="1" />
            <max value="1" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
                <code value="4201000179104" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.code">
            <path value="DiagnosticReport.code" />
            <short value="Code">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Code" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="code" />
                    </extension>
                </extension>
            </short>
            <definition value="Code des Befundberichts">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Code des Befundberichts" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="code of the diagnostic report" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.code.coding">
            <path value="DiagnosticReport.code.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
        </element>
        <element id="DiagnosticReport.code.coding:sct">
            <path value="DiagnosticReport.code.coding" />
            <sliceName value="sct" />
            <min value="0" />
            <max value="1" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.code.coding:loinc">
            <path value="DiagnosticReport.code.coding" />
            <sliceName value="loinc" />
            <min value="0" />
            <max value="1" />
            <patternCoding>
                <system value="http://loinc.org" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.subject">
            <path value="DiagnosticReport.subject" />
            <short value="Person">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Person" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="person" />
                    </extension>
                </extension>
            </short>
            <definition value="Person, auf die sich die Befundbericht bezieht">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Person, auf die sich die Befundbericht bezieht" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="person, which this report is about" />
                    </extension>
                </extension>
            </definition>
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.encounter">
            <path value="DiagnosticReport.encounter" />
            <short value="Versorgungssstellenkontakt">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Versorgungssstellenkontakt" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Encounter" />
                    </extension>
                </extension>
            </short>
            <definition value="Fall-Referenz auf den Versorgungssstellenkontakt">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Fall-Referenz auf den Versorgungssstellenkontakt" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="encounter reference" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.effective[x]">
            <path value="DiagnosticReport.effective[x]" />
            <slicing>
                <discriminator>
                    <type value="type" />
                    <path value="$this" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
            <short value="Erstellungsdatum">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Erstellungsdatum" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="effective[x]" />
                    </extension>
                </extension>
            </short>
            <definition value="Zeitpunkt der Erstellung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Zeitpunkt der Erstellung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="date of creation" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.effective[x]:effectiveDateTime">
            <path value="DiagnosticReport.effective[x]" />
            <sliceName value="effectiveDateTime" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="dateTime" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.effective[x]:effectivePeriod">
            <path value="DiagnosticReport.effective[x]" />
            <sliceName value="effectivePeriod" />
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Period" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.issued">
            <path value="DiagnosticReport.issued" />
            <short value="Erstellungszeitpunkt">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Erstellungszeitpunkt" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="time of creation" />
                    </extension>
                </extension>
            </short>
            <definition value="Zeit an der der Bericht erstellt wurde">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Zeit an der der Bericht erstellt wurde" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="timestamp of creation of the report" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.result">
            <path value="DiagnosticReport.result" />
            <short value="Ergebnis">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Ergebnis" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="result" />
                    </extension>
                </extension>
            </short>
            <definition value="Ergebnis einer Beobachtung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Ergebnis einer Beobachtung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="result of an observation" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.imagingStudy">
            <path value="DiagnosticReport.imagingStudy" />
            <short value="Bildgebungsstudie">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Bildgebungsstudie" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="imaging study" />
                    </extension>
                </extension>
            </short>
            <definition value="Studie, die die vollst&#228;ndige Bildgebung umfasst">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Studie, die die vollst&#228;ndige Bildgebung umfasst" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="study with all images" />
                    </extension>
                </extension>
            </definition>
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-bildgebungsstudie" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusion">
            <path value="DiagnosticReport.conclusion" />
            <short value="Fazit">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Fazit" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="conclusion" />
                    </extension>
                </extension>
            </short>
            <definition value="Fazit zur aktuellen Befundung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Fazit zur aktuellen Befundung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="conclusion of the actual report" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusionCode">
            <path value="DiagnosticReport.conclusionCode" />
            <short value="Strukturiertes Fazit">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Strukturiertes Fazit" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="structured conclusion" />
                    </extension>
                </extension>
            </short>
            <definition value="Fazit, welches strukturiert &#252;ber Codes dargestellt wird">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Fazit, welches strukturiert &#252;ber Codes dargestellt wird" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="conclusion presented with structured codes" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusionCode.coding">
            <path value="DiagnosticReport.conclusionCode.coding" />
            <slicing>
                <discriminator>
                    <type value="pattern" />
                    <path value="$this" />
                </discriminator>
                <rules value="open" />
            </slicing>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusionCode.coding:icd10-gm">
            <path value="DiagnosticReport.conclusionCode.coding" />
            <sliceName value="icd10-gm" />
            <min value="0" />
            <max value="*" />
            <patternCoding>
                <system value="http://fhir.de/CodeSystem/bfarm/icd-10-gm" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusionCode.coding:sct">
            <path value="DiagnosticReport.conclusionCode.coding" />
            <sliceName value="sct" />
            <min value="0" />
            <max value="*" />
            <patternCoding>
                <system value="http://snomed.info/sct" />
            </patternCoding>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.conclusionCode.coding:sct.code">
            <path value="DiagnosticReport.conclusionCode.coding.code" />
            <binding>
                <strength value="preferred" />
                <valueSet value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-coding" />
            </binding>
        </element>
        <element id="DiagnosticReport.presentedForm">
            <path value="DiagnosticReport.presentedForm" />
            <short value="Anhang">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Anhang" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Attachment" />
                    </extension>
                </extension>
            </short>
            <definition value="zus&#228;tzlicher wichtiger Anhang">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="zus&#228;tzlicher wichtiger Anhang" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="additional attachment to the report" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-bildgebung-radiologischer-befund",
    "extension":  [
        {
            "url": "https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-ex-meta-license-codeable",
            "valueCodeableConcept": {
                "coding":  [
                    {
                        "code": "CC-BY-4.0",
                        "system": "http://hl7.org/fhir/spdx-license",
                        "display": "Creative Commons Attribution 4.0 International"
                    }
                ]
            }
        }
    ],
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund",
    "version": "2025.0.0",
    "name": "MII_PR_Bildgebung_Radiologischer_Befund",
    "_name": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII_PR_Imaging_Diagnostic_Report"
                    }
                ]
            }
        ]
    },
    "title": "MII PR Bildgebung Radiologischer Befund",
    "_title": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII PR Imaging Diagnostic Report"
                    }
                ]
            }
        ]
    },
    "status": "active",
    "date": "2025-01-01",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Diese Ressource beschreibt einen radiologischen Befund",
    "_description": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "The profile describes a diagnostic report for a radiological image."
                    }
                ]
            }
        ]
    },
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "DiagnosticReport",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "DiagnosticReport.id",
                "path": "DiagnosticReport.id",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.meta",
                "path": "DiagnosticReport.meta",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.meta.source",
                "path": "DiagnosticReport.meta.source",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.meta.profile",
                "path": "DiagnosticReport.meta.profile",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.extension",
                "path": "DiagnosticReport.extension",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "value",
                            "path": "url"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                }
            },
            {
                "id": "DiagnosticReport.extension:supportingInfo",
                "path": "DiagnosticReport.extension",
                "sliceName": "supportingInfo",
                "short": "Zusatzinformation",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Zusatzinformation"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "additional information"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Zusatzinformation zum Befundbericht",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Zusatzinformation zum Befundbericht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "additional information for the report"
                                }
                            ]
                        }
                    ]
                },
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.extension:supportingInfo.extension:type",
                "path": "DiagnosticReport.extension.extension",
                "sliceName": "type",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.extension:supportingInfo.extension:reference",
                "path": "DiagnosticReport.extension.extension",
                "sliceName": "reference",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.extension:supportingInfo.extension:reference.value[x]",
                "path": "DiagnosticReport.extension.extension.value[x]",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
                            "http://hl7.org/fhir/StructureDefinition/Procedure"
                        ]
                    }
                ]
            },
            {
                "id": "DiagnosticReport.basedOn",
                "path": "DiagnosticReport.basedOn",
                "short": "Anforderung",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Anforderung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "request"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Anforderung, die den Befundbericht ausgelöst hat",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Anforderung, die den Befundbericht ausgelöst hat"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "request, which triggered the report"
                                }
                            ]
                        }
                    ]
                },
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-anforderung-bildgebung",
                            "http://hl7.org/fhir/StructureDefinition/CarePlan"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.status",
                "path": "DiagnosticReport.status",
                "short": "Status",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Status"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "status"
                                }
                            ]
                        }
                    ]
                },
                "definition": "angemeldet | unvollständig | vorläufig | endgültig | geändert | korrigiert | angefügt | abgebrochen | fehlerhafte Eingabe | unbekannt",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "angemeldet | unvollständig | vorläufig | endgültig | geändert | korrigiert | angefügt | abgebrochen | fehlerhafte Eingabe | unbekannt"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.category",
                "path": "DiagnosticReport.category",
                "short": "Kategorie",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Kategorie"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "category"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Kategorie des Befundberichts",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Kategorie des Befundberichts"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "category of the diagnostic report"
                                }
                            ]
                        }
                    ]
                },
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.category.coding",
                "path": "DiagnosticReport.category.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "min": 1,
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.category.coding:loinc",
                "path": "DiagnosticReport.category.coding",
                "sliceName": "loinc",
                "min": 0,
                "max": "*",
                "patternCoding": {
                    "code": "18748-4",
                    "system": "http://loinc.org"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.category.coding:diagnostic-service-sections",
                "path": "DiagnosticReport.category.coding",
                "sliceName": "diagnostic-service-sections",
                "min": 0,
                "max": "*",
                "patternCoding": {
                    "code": "RAD",
                    "system": "http://terminology.hl7.org/CodeSystem/v2-0074"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.category.coding:sct",
                "path": "DiagnosticReport.category.coding",
                "sliceName": "sct",
                "min": 1,
                "max": "1",
                "patternCoding": {
                    "code": "4201000179104",
                    "system": "http://snomed.info/sct"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.code",
                "path": "DiagnosticReport.code",
                "short": "Code",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Code"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "code"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Code des Befundberichts",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Code des Befundberichts"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "code of the diagnostic report"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.code.coding",
                "path": "DiagnosticReport.code.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                }
            },
            {
                "id": "DiagnosticReport.code.coding:sct",
                "path": "DiagnosticReport.code.coding",
                "sliceName": "sct",
                "min": 0,
                "max": "1",
                "patternCoding": {
                    "system": "http://snomed.info/sct"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.code.coding:loinc",
                "path": "DiagnosticReport.code.coding",
                "sliceName": "loinc",
                "min": 0,
                "max": "1",
                "patternCoding": {
                    "system": "http://loinc.org"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.subject",
                "path": "DiagnosticReport.subject",
                "short": "Person",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Person"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "person"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Person, auf die sich die Befundbericht bezieht",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Person, auf die sich die Befundbericht bezieht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "person, which this report is about"
                                }
                            ]
                        }
                    ]
                },
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.encounter",
                "path": "DiagnosticReport.encounter",
                "short": "Versorgungssstellenkontakt",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Versorgungssstellenkontakt"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Encounter"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Fall-Referenz auf den Versorgungssstellenkontakt",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Fall-Referenz auf den Versorgungssstellenkontakt"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "encounter reference"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.effective[x]",
                "path": "DiagnosticReport.effective[x]",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "type",
                            "path": "$this"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                },
                "short": "Erstellungsdatum",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Erstellungsdatum"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "effective[x]"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Zeitpunkt der Erstellung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Zeitpunkt der Erstellung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "date of creation"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.effective[x]:effectiveDateTime",
                "path": "DiagnosticReport.effective[x]",
                "sliceName": "effectiveDateTime",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "dateTime"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.effective[x]:effectivePeriod",
                "path": "DiagnosticReport.effective[x]",
                "sliceName": "effectivePeriod",
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Period"
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.issued",
                "path": "DiagnosticReport.issued",
                "short": "Erstellungszeitpunkt",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Erstellungszeitpunkt"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "time of creation"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Zeit an der der Bericht erstellt wurde",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Zeit an der der Bericht erstellt wurde"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "timestamp of creation of the report"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.result",
                "path": "DiagnosticReport.result",
                "short": "Ergebnis",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Ergebnis"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "result"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Ergebnis einer Beobachtung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Ergebnis einer Beobachtung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "result of an observation"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.imagingStudy",
                "path": "DiagnosticReport.imagingStudy",
                "short": "Bildgebungsstudie",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Bildgebungsstudie"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "imaging study"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Studie, die die vollständige Bildgebung umfasst",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Studie, die die vollständige Bildgebung umfasst"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "study with all images"
                                }
                            ]
                        }
                    ]
                },
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-bildgebungsstudie"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusion",
                "path": "DiagnosticReport.conclusion",
                "short": "Fazit",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Fazit"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "conclusion"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Fazit zur aktuellen Befundung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Fazit zur aktuellen Befundung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "conclusion of the actual report"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusionCode",
                "path": "DiagnosticReport.conclusionCode",
                "short": "Strukturiertes Fazit",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Strukturiertes Fazit"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "structured conclusion"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Fazit, welches strukturiert über Codes dargestellt wird",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Fazit, welches strukturiert über Codes dargestellt wird"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "conclusion presented with structured codes"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusionCode.coding",
                "path": "DiagnosticReport.conclusionCode.coding",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "pattern",
                            "path": "$this"
                        }
                    ],
                    "rules": "open"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusionCode.coding:icd10-gm",
                "path": "DiagnosticReport.conclusionCode.coding",
                "sliceName": "icd10-gm",
                "min": 0,
                "max": "*",
                "patternCoding": {
                    "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusionCode.coding:sct",
                "path": "DiagnosticReport.conclusionCode.coding",
                "sliceName": "sct",
                "min": 0,
                "max": "*",
                "patternCoding": {
                    "system": "http://snomed.info/sct"
                },
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.conclusionCode.coding:sct.code",
                "path": "DiagnosticReport.conclusionCode.coding.code",
                "binding": {
                    "strength": "preferred",
                    "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-coding"
                }
            },
            {
                "id": "DiagnosticReport.presentedForm",
                "path": "DiagnosticReport.presentedForm",
                "short": "Anhang",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Anhang"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Attachment"
                                }
                            ]
                        }
                    ]
                },
                "definition": "zusätzlicher wichtiger Anhang",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "zusätzlicher wichtiger Anhang"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "additional attachment to the report"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            }
        ]
    }
}

MII PR Bildgebung Radiologischer Befund

FHIR	Datensatz	Erklaerung
DiagnosticReport	Bildgebung.Befundbericht	Bericht einer radiologischen Befundung
DiagnosticReport.basedOn	Bildgebung.Befundbericht.AnforderndeMassnahme	Basiert auf einer ServiceRequest-Anfrage.
DiagnosticReport.status	Bildgebung.Befundbericht.Status	Status des Befundberichts.
DiagnosticReport.category	Bildgebung.Befundbericht.Kategorie	Kategorisiert die Untersuchungsart
DiagnosticReport.code	Bildgebung.Befundbericht.Code	Festgelegter Code des Befundberichts. Hier Radiologischer Befund
DiagnosticReport.subject	Bildgebung.Befundbericht.Person	Die Person, für die der Befundbericht erstellt wurde. Hier sollte das MII KDS-Modul Person referenziert werden
DiagnosticReport.encounter	Bildgebung.Befundbericht.Fall	Referenz über Fall auf den Versorgungsstellenkontakt. Hier soll das MII KDS-Modul Fall in Stufe 3 referenziert werden
DiagnosticReport.effectiveDateTime	Bildgebung.Befundbericht.Zeitpunkt	Klinisch relevanter Zeitpunkt, auf den sich der Bericht bezieht.
DiagnosticReport.effectivePeriod	Bildgebung.Befundbericht.Periode	Klinisch relevante Periode, auf die sich der Bericht bezieht.
DiagnosticReport.issued	Bildgebung.Befundbericht.ZeitpunktErstellung	Zeitpunkt der Erstellung des Berichts.
DiagnosticReport.result	Bildgebung.Befundbericht.Beobachtung	Referenz auf die generische Beobachtung.
DiagnosticReport.study	Bildgebung.Befundbericht.Studienbezug	Bezug auf die zugehörige(n) Bildgebungsstudie(n).
DiagnosticReport.conclusion	Bildgebung.Befundbericht.InterpretationBeobachtung	Freitextinterpretation der Beobachtung.
DiagnosticReport.conclusionCode	Bildgebung.Befundbericht.StrukturierteInterpretation	Strukturierte Interpretation der Beobachtung.
DiagnosticReport.supportingInfo.reference	Bildgebung.Befundbericht.Zusatzinformation	Referenz auf weitere Befundberichte zum Patienten. Backport aus FHIR R5
DiagnosticReport.presentedForm	Bildgebung.Befundbericht.Dokumentenanhang	Anhang der Dokumente und Bilder.

Suchparameter

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

Name	Definition	Type	Expectation
_id	http://hl7.org/fhir/SearchParameter/Resource-id	token	SHALL
_lastUpdated	http://hl7.org/fhir/SearchParameter/Resource-lastUpdated	date	SHALL
_profile	http://hl7.org/fhir/SearchParameter/Resource-profile	uri	SHALL
_source	http://hl7.org/fhir/SearchParameter/Resource-source	uri	SHALL
supporting-info	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-diagnostic-report-supporting-info	reference	SHALL
based-on	http://hl7.org/fhir/SearchParameter/DiagnosticReport-based-on	reference	SHALL
status	http://hl7.org/fhir/SearchParameter/DiagnosticReport-status	token	SHALL
category	http://hl7.org/fhir/SearchParameter/DiagnosticReport-category	token	SHALL
code	http://hl7.org/fhir/SearchParameter/clinical-code	token	SHALL
patient	http://hl7.org/fhir/SearchParameter/clinical-patient	reference	SHALL
encounter	http://hl7.org/fhir/SearchParameter/clinical-encounter	reference	SHALL
date	http://hl7.org/fhir/SearchParameter/clinical-date	date	SHALL
issued	http://hl7.org/fhir/SearchParameter/DiagnosticReport-issued	date	SHALL
result	http://hl7.org/fhir/SearchParameter/DiagnosticReport-result	reference	SHALL
imaging-study	https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-pr-meta-searchparameter	reference	SHALL
conclusion-text	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-diagnostic-report-conclusion	string	SHALL
conclusion	http://hl7.org/fhir/SearchParameter/DiagnosticReport-conclusion	token	SHALL

Beispiele

Beispiel einer DiagnosticReport-Ressource

{
    "resourceType": "DiagnosticReport",
    "id": "mii-exa-bildgebung-radiologischer-Befund",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund"
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "code": "4201000179104",
                    "system": "http://snomed.info/sct"
                }
            ]
        }
    ],
    "extension":  [
        {
            "extension":  [
                {
                    "url": "type",
                    "valueCodeableConcept": {
                        "coding":  [
                            {
                                "code": "SCI",
                                "system": "http://terminology.hl7.org/CodeSystem/v2-0936",
                                "display": "Supporting Clinical Information"
                            }
                        ]
                    }
                },
                {
                    "url": "reference",
                    "valueReference": {
                        "reference": "DiagnosticReport/DiagRepExample"
                    }
                }
            ],
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo"
        }
    ],
    "basedOn":  [
        {
            "reference": "ServiceRequest/mii-exa-bildgebung-anforderung-bildgebung"
        }
    ],
    "status": "final",
    "code": {
        "coding":  [
            {
                "code": "4231000179109",
                "system": "http://snomed.info/sct",
                "display": "Mammography report"
            }
        ]
    },
    "subject": {
        "reference": "Patient/PatExample"
    },
    "encounter": {
        "reference": "Encounter/EncExample"
    },
    "effectiveDateTime": "2024-07-19T12:03:30+02:00",
    "issued": "2024-07-19T12:03:30+02:00",
    "result":  [
        {
            "reference": "Observation/mii-exa-bildgebung-radiologische-beobachtung"
        }
    ],
    "imagingStudy":  [
        {
            "reference": "ImagingStudy/mii-exa-bildgebung-bildgebungsstudie-ct"
        }
    ],
    "conclusion": "There are suspicious microcalcifications in the upper outer quadrant in the left breast",
    "conclusionCode":  [
        {
            "coding":  [
                {
                    "code": "12747003",
                    "system": "http://snomed.info/sct",
                    "display": "Microcalcification, calcified structure (morphologic abnormality)"
                }
            ]
        }
    ]
}