Diese Composition-Ressource wird verwendet, um semistrukturierte Befundberichte bildgebender Verfahren zu erfassen.
Name | Status | Version | Canonical | Basis |
---|---|---|---|---|
MII_PR_Bildgebung_Semistrukt_Befundbericht | active | 2025.0.0 | https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-semistrukt-befundbericht | http://hl7.org/fhir/StructureDefinition/Composition |
MII_PR_Bildgebung_Semistrukt_Befundbericht (Composition) | I | Composition | |
id | S Σ | 0..1 | string |
meta | S Σ | 0..1 | Meta |
id | 0..1 | string | |
extension | I | 0..* | Extension |
versionId | Σ | 0..1 | id |
lastUpdated | Σ | 0..1 | instant |
source | S Σ | 0..1 | uri |
profile | S Σ | 0..* | canonical(StructureDefinition) |
security | Σ | 0..* | CodingBinding |
tag | Σ | 0..* | Coding |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | I | 0..* | Extension |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..1 | Identifier |
status | S Σ ?! | 1..1 | codeBinding |
type | S Σ | 1..1 | CodeableConceptBinding |
category | Σ | 0..* | CodeableConcept |
subject | S Σ I | 1..1 | Reference(Patient) |
encounter | Σ I | 0..1 | Reference(Encounter) |
date | S Σ | 1..1 | dateTime |
author | S Σ I | 1..* | Reference(Practitioner) |
title | S Σ | 1..1 | string |
confidentiality | Σ | 0..1 | codeBinding |
attester | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
mode | 1..1 | codeBinding | |
time | 0..1 | dateTime | |
party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) |
custodian | Σ I | 0..1 | Reference(Organization) |
relatesTo | 0..* | BackboneElement | |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | 1..1 | codeBinding | |
target[x] | 1..1 | ||
targetIdentifier | Identifier | ||
targetReference | Reference(Composition) | ||
event | Σ | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
code | Σ | 0..* | CodeableConcept |
period | Σ I | 0..1 | Period |
detail | Σ I | 0..* | Reference(Resource) |
section | S I | 1..* | BackboneElement |
(All Slices) | |||
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
title | S | 0..1 | string |
code | S | 0..1 | CodeableConcept |
author | S I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) |
focus | I | 0..1 | Reference(Resource) |
text | S I | 0..1 | Narrative |
mode | 0..1 | codeBinding | |
orderedBy | 0..1 | CodeableConceptBinding | |
entry | S I | 1..* | Reference(Resource) |
emptyReason | I | 0..1 | CodeableConceptBinding |
section | S I | 0..* | see (section) |
diagRep | I | 1..1 | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
title | S | 0..1 | string |
code | S | 0..1 | CodeableConcept |
author | S I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) |
focus | I | 0..1 | Reference(Resource) |
text | S I | 0..1 | Narrative |
mode | 0..1 | codeBinding | |
orderedBy | 0..1 | CodeableConceptBinding | |
entry | S I | 1..* | Reference(MII_PR_Bildgebung_Radiologischer_Befund) |
emptyReason | I | 0..1 | CodeableConceptBinding |
section | S I | 0..* | see (section) |
Dieses Profil bietet die Möglichkeit, den Befundbericht in einer semi-strukturierten Weise abzubilden. Es dient damit als Ergänzung zum eigentlichen Befundbericht |
Feldname | Kurzbeschreibung |
---|---|
Composition.id | |
Composition.meta | |
Composition.meta.source | |
Composition.meta.profile | |
Composition.status | Status |
Composition.type | Kompositionstyp |
Composition.subject | Person |
Composition.date | Erstellungsdatum |
Composition.author | Autor |
Composition.title | Titel |
Composition.section | Befundabschnitt |
Composition.section.title | Befundabschnittstitel |
Composition.section.code | Abschnitttyp |
Composition.section.author | Abschnittsautor |
Composition.section.text | Abschnitttext |
Composition.section.entry | Abschnittseintrag |
Composition.section.section | weiterer Abschnitt |
Composition.section:diagRep.title | |
Composition.section:diagRep.code | |
Composition.section:diagRep.author | |
Composition.section:diagRep.text | |
Composition.section:diagRep.entry | |
Composition.section:diagRep.section |
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="mii-pr-bildgebung-semistrukt-befundbericht" /> <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-semistrukt-befundbericht" /> <version value="2025.0.0" /> <name value="MII_PR_Bildgebung_Semistrukt_Befundbericht"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="MII_PR_Imaging_Composition" /> </extension> </extension> </name> <title value="MII PR Bildgebung Semistrukturierter Befundbericht"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="MII PR Imaging Composition" /> </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="Dieses Profil bietet die Möglichkeit, den Befundbericht in einer semi-strukturierten Weise abzubilden. Es dient damit als Ergänzung zum eigentlichen Befundbericht"> <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 semistructured report. It is an addition for the main medical report." /> </extension> </extension> </description> <fhirVersion value="4.0.1" /> <kind value="resource" /> <abstract value="false" /> <type value="Composition" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Composition" /> <derivation value="constraint" /> <differential> <element id="Composition.id"> <path value="Composition.id" /> <mustSupport value="true" /> </element> <element id="Composition.meta"> <path value="Composition.meta" /> <mustSupport value="true" /> </element> <element id="Composition.meta.source"> <path value="Composition.meta.source" /> <mustSupport value="true" /> </element> <element id="Composition.meta.profile"> <path value="Composition.meta.profile" /> <mustSupport value="true" /> </element> <element id="Composition.status"> <path value="Composition.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="vorläufig | engültig | geändert | fehlerhafte Eingabe"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="vorläufig | engültig | geändert | fehlerhafte Eingabe" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="preliminary | final | amended | entered-in-error" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.type"> <path value="Composition.type" /> <short value="Kompositionstyp"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Kompositionstyp" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="compositiontype" /> </extension> </extension> </short> <definition value="Typ der Komposition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Typ der Komposition" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="type of the composition" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.subject"> <path value="Composition.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 Komposition 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 Komposition 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 composition 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="Composition.date"> <path value="Composition.date" /> <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="date" /> </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="Composition.author"> <path value="Composition.author" /> <short value="Autor"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Autor" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="author" /> </extension> </extension> </short> <definition value="Autor der Komposition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Autor der Komposition" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="author of the composition" /> </extension> </extension> </definition> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Practitioner" /> </type> <mustSupport value="true" /> </element> <element id="Composition.title"> <path value="Composition.title" /> <short value="Titel"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Titel" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="title" /> </extension> </extension> </short> <definition value="Titel der Komposition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Titel der Komposition" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="title of this composition" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section"> <path value="Composition.section" /> <slicing> <discriminator> <type value="profile" /> <path value="Composition.section.entry.resolve()" /> </discriminator> <rules value="open" /> </slicing> <short value="Befundabschnitt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Befundabschnitt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section" /> </extension> </extension> </short> <definition value="1. Abschnitt immer der Befundbericht, 2.-X. Abschnitt können Beobachtungen oder Freitext sein. Unterteilt in Titel, Code, Autor, Text und Eintrag"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="1. Abschnitt immer der Befundbericht, 2.-X. Abschnitt können Beobachtungen oder Freitext sein. Unterteilt in Titel, Code, Autor, Text und Eintrag" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="1. section is the report, 2.-X. sections are observations or text. Subdivided in title, code, author, text and entry" /> </extension> </extension> </definition> <min value="1" /> <mustSupport value="true" /> </element> <element id="Composition.section.title"> <path value="Composition.section.title" /> <short value="Befundabschnittstitel"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Befundabschnittstitel" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="sectiontitle" /> </extension> </extension> </short> <definition value="Titel des Befundabschnitt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Titel des Befundabschnitt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section title" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section.code"> <path value="Composition.section.code" /> <short value="Abschnitttyp"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Abschnitttyp" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section type" /> </extension> </extension> </short> <definition value="Typ des Abschnitts"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Typ des Abschnitts" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="type of section" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section.author"> <path value="Composition.section.author" /> <short value="Abschnittsautor"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Abschnittsautor" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section-author" /> </extension> </extension> </short> <definition value="Autor des Abschnitts"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Autor des Abschnitts" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="author of this section" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section.text"> <path value="Composition.section.text" /> <short value="Abschnitttext"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Abschnitttext" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section text" /> </extension> </extension> </short> <definition value="Text im Abschnitt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Text im Abschnitt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="text of this section" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section.entry"> <path value="Composition.section.entry" /> <short value="Abschnittseintrag"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Abschnittseintrag" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="section entry" /> </extension> </extension> </short> <definition value="Eintrag in einem Abschnitt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="Eintrag in einem Abschnitt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="entry of this section" /> </extension> </extension> </definition> <min value="1" /> <mustSupport value="true" /> </element> <element id="Composition.section.section"> <path value="Composition.section.section" /> <short value="weiterer Abschnitt"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="weiterer Abschnitt" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="additional section" /> </extension> </extension> </short> <definition value="weiterer Abschnitt in der Komposition"> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="de-DE" /> </extension> <extension url="content"> <valueString value="weiterer Abschnitt in der Komposition" /> </extension> </extension> <extension url="http://hl7.org/fhir/StructureDefinition/translation"> <extension url="lang"> <valueCode value="en-US" /> </extension> <extension url="content"> <valueString value="additional section of this composition" /> </extension> </extension> </definition> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep"> <path value="Composition.section" /> <sliceName value="diagRep" /> <min value="1" /> <max value="1" /> </element> <element id="Composition.section:diagRep.title"> <path value="Composition.section.title" /> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep.code"> <path value="Composition.section.code" /> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep.author"> <path value="Composition.section.author" /> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep.text"> <path value="Composition.section.text" /> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep.entry"> <path value="Composition.section.entry" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund" /> </type> <mustSupport value="true" /> </element> <element id="Composition.section:diagRep.section"> <path value="Composition.section.section" /> <mustSupport value="true" /> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "id": "mii-pr-bildgebung-semistrukt-befundbericht", "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-semistrukt-befundbericht", "version": "2025.0.0", "name": "MII_PR_Bildgebung_Semistrukt_Befundbericht", "_name": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "MII_PR_Imaging_Composition" } ] } ] }, "title": "MII PR Bildgebung Semistrukturierter Befundbericht", "_title": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "MII PR Imaging Composition" } ] } ] }, "status": "active", "date": "2025-01-01", "publisher": "Medizininformatik Initiative", "contact": [ { "telecom": [ { "system": "url", "value": "https://www.medizininformatik-initiative.de" } ] } ], "description": "Dieses Profil bietet die Möglichkeit, den Befundbericht in einer semi-strukturierten Weise abzubilden. Es dient damit als Ergänzung zum eigentlichen Befundbericht", "_description": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "The profile describes a semistructured report. It is an addition for the main medical report." } ] } ] }, "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "Composition", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Composition", "derivation": "constraint", "differential": { "element": [ { "id": "Composition.id", "path": "Composition.id", "mustSupport": true }, { "id": "Composition.meta", "path": "Composition.meta", "mustSupport": true }, { "id": "Composition.meta.source", "path": "Composition.meta.source", "mustSupport": true }, { "id": "Composition.meta.profile", "path": "Composition.meta.profile", "mustSupport": true }, { "id": "Composition.status", "path": "Composition.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": "vorläufig | engültig | geändert | fehlerhafte Eingabe", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "vorläufig | engültig | geändert | fehlerhafte Eingabe" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "preliminary | final | amended | entered-in-error" } ] } ] }, "mustSupport": true }, { "id": "Composition.type", "path": "Composition.type", "short": "Kompositionstyp", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Kompositionstyp" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "compositiontype" } ] } ] }, "definition": "Typ der Komposition", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Typ der Komposition" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "type of the composition" } ] } ] }, "mustSupport": true }, { "id": "Composition.subject", "path": "Composition.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 Komposition bezieht", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Person, auf die sich die Komposition bezieht" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "person, which this composition is about" } ] } ] }, "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] } ], "mustSupport": true }, { "id": "Composition.date", "path": "Composition.date", "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": "date" } ] } ] }, "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": "Composition.author", "path": "Composition.author", "short": "Autor", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Autor" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "author" } ] } ] }, "definition": "Autor der Komposition", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Autor der Komposition" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "author of the composition" } ] } ] }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ] } ], "mustSupport": true }, { "id": "Composition.title", "path": "Composition.title", "short": "Titel", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Titel" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "title" } ] } ] }, "definition": "Titel der Komposition", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Titel der Komposition" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "title of this composition" } ] } ] }, "mustSupport": true }, { "id": "Composition.section", "path": "Composition.section", "slicing": { "discriminator": [ { "type": "profile", "path": "Composition.section.entry.resolve()" } ], "rules": "open" }, "short": "Befundabschnitt", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Befundabschnitt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section" } ] } ] }, "definition": "1. Abschnitt immer der Befundbericht, 2.-X. Abschnitt können Beobachtungen oder Freitext sein. Unterteilt in Titel, Code, Autor, Text und Eintrag", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "1. Abschnitt immer der Befundbericht, 2.-X. Abschnitt können Beobachtungen oder Freitext sein. Unterteilt in Titel, Code, Autor, Text und Eintrag" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "1. section is the report, 2.-X. sections are observations or text. Subdivided in title, code, author, text and entry" } ] } ] }, "min": 1, "mustSupport": true }, { "id": "Composition.section.title", "path": "Composition.section.title", "short": "Befundabschnittstitel", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Befundabschnittstitel" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "sectiontitle" } ] } ] }, "definition": "Titel des Befundabschnitt", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Titel des Befundabschnitt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section title" } ] } ] }, "mustSupport": true }, { "id": "Composition.section.code", "path": "Composition.section.code", "short": "Abschnitttyp", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Abschnitttyp" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section type" } ] } ] }, "definition": "Typ des Abschnitts", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Typ des Abschnitts" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "type of section" } ] } ] }, "mustSupport": true }, { "id": "Composition.section.author", "path": "Composition.section.author", "short": "Abschnittsautor", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Abschnittsautor" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section-author" } ] } ] }, "definition": "Autor des Abschnitts", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Autor des Abschnitts" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "author of this section" } ] } ] }, "mustSupport": true }, { "id": "Composition.section.text", "path": "Composition.section.text", "short": "Abschnitttext", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Abschnitttext" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section text" } ] } ] }, "definition": "Text im Abschnitt", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Text im Abschnitt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "text of this section" } ] } ] }, "mustSupport": true }, { "id": "Composition.section.entry", "path": "Composition.section.entry", "short": "Abschnittseintrag", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Abschnittseintrag" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "section entry" } ] } ] }, "definition": "Eintrag in einem Abschnitt", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Eintrag in einem Abschnitt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "entry of this section" } ] } ] }, "min": 1, "mustSupport": true }, { "id": "Composition.section.section", "path": "Composition.section.section", "short": "weiterer Abschnitt", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "weiterer Abschnitt" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "additional section" } ] } ] }, "definition": "weiterer Abschnitt in der Komposition", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "weiterer Abschnitt in der Komposition" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "additional section of this composition" } ] } ] }, "mustSupport": true }, { "id": "Composition.section:diagRep", "path": "Composition.section", "sliceName": "diagRep", "min": 1, "max": "1" }, { "id": "Composition.section:diagRep.title", "path": "Composition.section.title", "mustSupport": true }, { "id": "Composition.section:diagRep.code", "path": "Composition.section.code", "mustSupport": true }, { "id": "Composition.section:diagRep.author", "path": "Composition.section.author", "mustSupport": true }, { "id": "Composition.section:diagRep.text", "path": "Composition.section.text", "mustSupport": true }, { "id": "Composition.section:diagRep.entry", "path": "Composition.section.entry", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund" ] } ], "mustSupport": true }, { "id": "Composition.section:diagRep.section", "path": "Composition.section.section", "mustSupport": true } ] } }
FHIR | Datensatz | Erklaerung |
---|---|---|
Composition | Bildgebung.SemistrukturiertesBefunddokument | Abbildung des Befunds über generische Composition. |
Composition.status | Bildgebung.SemistrukturiertesBefunddokument.Status | Status des semistrukturierten Befundberichts. |
Composition.type | Bildgebung.SemistrukturiertesBefunddokument.Typ | bestimmte Dokumentenart in LOINC codiert. |
Composition.subject | Bildgebung.SemistrukturiertesBefunddokument.Person | Person, auf die sich das Dokument bezieht. Hier sollte das MII KDS-Profil Person referenziert werden. |
Composition.date | Bildgebung.SemistrukturiertesBefunddokument.DatumUhrzeit | Datum und Uhrzeit der Bearbeitung |
Composition.author | Bildgebung.SemistrukturiertesBefunddokument.Autor | Referenz auf den Autor der Beschreibung. |
Composition.title | Bildgebung.SemistrukturiertesBefunddokument.Titel | Titel des Befunddokuments |
Composition.section | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt | Befundabschnitt des semistrukturierten Befunddokuments. Der erste Abschnitt ist immer ein Befundbericht. Alle weiteren Abschnitte können Freitext oder codierte Beobachtungen sein. |
Composition.section.title | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Titel | Titel des Befundabschnitts. |
Composition.section.code | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Art | Art des Befundabschnitts. |
Composition.section.author | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Autor | Autor des jeweiligen Befundabschnitts. Kann auch von einer KI generiert werden. |
Composition.section.text | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Text | Textueller Inhalt des Befundabschnitts. |
Composition.section.entry | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Eintrag | Referenz auf eine Observation, die zum Eintrag des Befundabschnitts gehört. |
Composition.section.section | Bildgebung.SemistrukturiertesBefunddokument.Befundabschnitt.Unterabschnitt | Referenz auf einen weiteren Unterabschnitt. |
Suchparameter
Folgende Suchparameter sind für das Modul Bildgebung relevant, auch in Kombination:
Beispiele
Beispiel einer Composition-Ressource zur Darstellung des Befunds in verschiedenen Abschnitten. Dies bietet die Möglichkeit den Befund nicht nur als Freitext- oder strukturierter Form, sondern auch in semi-strukturierter Form kapitelweise darzustellen.
{ "resourceType": "Composition", "id": "mii-exa-bildgebung-semistrukt-befundbericht", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-semistrukt-befundbericht" ] }, "status": "final", "type": { "coding": [ { "code": "24604-1", "system": "http://loinc.org", "display": "MG Breast Diagnostics Limited View" } ] }, "subject": { "reference": "Patient/PatExample" }, "date": "2024-07-19T12:03:30+02:00", "author": [ { "reference": "Practitioner/PracExample1" } ], "title": "Mammographic Report", "section": [ { "title": "Left Breast", "code": { "coding": [ { "code": "66110-8", "system": "http://loinc.org", "display": "Breast Pathology biopsy report" } ] }, "author": [ { "reference": "Practitioner/PracExample2" } ], "entry": [ { "reference": "DiagnosticReport/mii-exa-bildgebung-radiologischer-Befund" } ], "section": [ { "entry": [ { "reference": "Observation/mii-exa-bildgebung-radiologische-beobachtung" } ] } ] } ] }