MII IG Befunde bildgebender Verfahren DE v2025

Observation

Diese Observation-Ressource wird verwendet, um eine radiologische Beobachtung zu erfassen. Die Ressource ist weitestgehend generisch ausgeführt, um so eine Vielzahl von codierter Befundung abbilden zu können. Beispiele wären hier eine Befudnung nach TNM etc. In R4 gibt es noch nicht die Möglichkeit die untersuchte Körperstruktur durch eine BodyStructure zu referenzieren, weshalb diese Möglichkeit aus R5 importiert wurde. Weiterhin wurde die Ressource um die Serien- und Instanzinformation aus der Bildstudie ergänzt, um hier sich direkt auf das jeweilige Bild beziehen zu können.

Name	Status	Version	Canonical	Basis
MII_PR_Bildgebung_Radiologische_Beobachtung	active	2025.0.0	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-beobachtung	http://hl7.org/fhir/StructureDefinition/Observation

Inhalt

MII_PR_Bildgebung_Radiologische_Beobachtung (Observation)	I		Observation	There are no (further) constraints on this element Element id Observation Short description Measurements and simple assertions Alternate names Vital Signs, Measurement, Results, Tests Definition Measurements and simple assertions made about a patient, device or other subject. Comments Used for simple observations such as device measurements, laboratory atomic results, vital signs, height, weight, smoking status, comments, etc. Other resources are used to provide context for observations such as laboratory reports, etc. Data type Observation 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()` obs-7: If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present `value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()` obs-6: dataAbsentReason SHALL only be present if Observation.value[x] is not present `dataAbsentReason.empty() or value.empty()` Mappings rim: Entity. Role, or Act workflow: Event sct-concept: < 363787002 \|Observable entity\| v2: OBX rim: Observation[classCode=OBS, moodCode=EVN]
id	S Σ	0..1	string	There are no (further) constraints on this element Element id Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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 Observation.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
SeriesUID	I	0..1	Extension(id)	Element id Observation.extension:SeriesUID Short description Serien UID Alternate names extensions, user content Definition UID einer DICOM-Serie 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(id) Extension URL https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-series-uid 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
SOPInstanzUID	I	0..1	Extension(id)	Element id Observation.extension:SOPInstanzUID Short description SOP Instanz UID Alternate names extensions, user content Definition UID einer SOP Instanz 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(id) Extension URL https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-sop-instanz-uid 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
bodyStructure	S I	0..*	Extension	Element id Observation.extension:bodyStructure Short description Körperstruktur Alternate names extensions, user content Definition Referenz auf eine Körperstruktur 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-Observation.bodyStructure 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 Observation.extension:bodyStructure.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 Observation.extension:bodyStructure.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 Observation.extension:bodyStructure.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-Observation.bodyStructure Mappings rim: N/A
value[x]		0..1		There are no (further) constraints on this element Element id Observation.extension:bodyStructure.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(MII_PR_Bildgebung_Koerperstruktur)	Data type Reference(MII_PR_Bildgebung_Koerperstruktur)
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id Observation.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 Observation.identifier Short description Business Identifier for observation Definition A unique identifier assigned to this observation. Requirements Allows observations to be distinguished and referenced. 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: OBX.21 For OBX segments from systems without OBX-21 support a combination of ORC/OBR and OBX must be negotiated between trading partners to uniquely identify the OBX segment. Depending on how V2 has been implemented each of these may be an option: 1) OBR-3 + OBX-3 + OBX-4 or 2) OBR-3 + OBR-4 + OBX-3 + OBX-4 or 2) some other way to uniquely ID the OBR/ORC + OBX-3 + OBX-4. rim: id
basedOn	Σ I	0..*	Reference(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	There are no (further) constraints on this element Element id Observation.basedOn Short description Fulfills plan, proposal or order Alternate names Fulfills Definition A plan, proposal or order that is fulfilled in whole or in part by this event. For example, a MedicationRequest may require a patient to have laboratory test performed before it is dispensed. Requirements Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. 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(CarePlan \| DeviceRequest \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest) 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 rim: .inboundRelationship[typeCode=COMP].source[moodCode=EVN]
partOf	S Σ I	0..*	Reference(MII_PR_Bildgebung_Radiologische_Befundungsprozedur)	Element id Observation.partOf Short description Teil von Alternate names Container Definition Teil einer Befundungprozedur Comments To link an Observation to an Encounter use `encounter`. See the Notes below for guidance on referencing another Observation. Data type Reference(MII_PR_Bildgebung_Radiologische_Befundungsprozedur) 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.partOf v2: Varies by domain rim: .outboundRelationship[typeCode=FLFS].target
status	S Σ ?!	1..1	codeBinding	Element id Observation.status Short description Status Definition angemeldet \| vorläufig \| endgültig \| geändert \| korrigiert \| abgebrochen \| fehlerhafte Eingabe \| unbekannt Requirements Need to track the status of individual results. Some results are finalized before the whole report is finalized. Comments This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid. Data type code Binding Codes providing the status of an observation. ObservationStatus (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 sct-concept: < 445584004 \|Report by finality status\| v2: OBX-11 rim: status Amended & Final are differentiated by whether it is the subject of a ControlAct event with a type of "revise"
category	S	0..*	CodeableConceptBinding	Element id Observation.category Short description Kategorie Definition Klassifikation in diagnostischen Fachbereich und Gruppe Requirements Used for filtering what observations are retrieved and displayed. Comments In addition to the required category valueset, this element allows various categorization schemes based on the owner’s definition of the category and effectively multiple categories can be used at once. The level of granularity is defined by the category concepts in the value set. Data type CodeableConcept Binding Codes for high level observation categories. ObservationCategoryCodes (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 w5: FiveWs.class rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
code	S Σ	1..1	CodeableConcept	Element id Observation.code Short description Code Alternate names Name Definition Ein Code für die zu befundende Beoabchtung Requirements Knowing what kind of observation is being made is essential to understanding the observation. Comments All code-value and, if present, component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Data type CodeableConcept Binding Codes identifying names of simple observations. LOINCCodes (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 workflow: Event.code w5: FiveWs.what[x] sct-concept: < 363787002 \|Observable entity\| OR < 386053000 \|Evaluation procedure\| v2: OBX-3 rim: code sct-attr: 116680003 \|Is a\|
subject	S Σ I	1..1	Reference(Patient)	Element id Observation.subject Short description Person Definition Person, auf die sich die Beobachtung bezieht Requirements Observations have no value if you don't know who or what they're about. Comments One would expect this element to be a cardinality of 1..1. The only circumstance in which the subject can be missing is when the observation is made by a device that does not know the patient. In this case, the observation SHALL be matched to a patient through some context/channel matching technique, and at this point, the observation should be updated. 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 rim: participation[typeCode=RTGT] w5: FiveWs.subject
focus	Σ I	0..*	Reference(Resource)	There are no (further) constraints on this element Element id Observation.focus Short description What the observation is about, when it is not about the subject of record Definition The actual focus of an observation when it is not the patient of record representing something or someone associated with the patient such as a spouse, parent, fetus, or donor. For example, fetus observations in a mother's record. The focus of an observation could also be an existing condition, an intervention, the subject's diet, another observation of the subject, or a body structure such as tumor or implanted device. An example use case would be using the Observation resource to capture whether the mother is trained to change her child's tracheostomy tube. In this example, the child is the patient of record and the mother is the focus. Comments Typically, an observation is made about the subject - a patient, or group of patients, location, or device - and the distinction between the subject and what is directly measured for an observation is specified in the observation code itself ( e.g., "Blood Glucose") and does not need to be represented separately using this element. Use `specimen` if a reference to a specimen is required. If a code is required instead of a resource use either `bodysite` for bodysites or the standard extension focusCode. Data type Reference(Resource) 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) w5: FiveWs.subject[x] v2: OBX-3 rim: participation[typeCode=SBJ] w5: FiveWs.subject
encounter	Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id Observation.encounter Short description Healthcare event during which this observation is made Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) during which this observation is made. Requirements For some observations it may be important to know the link between an observation and a particular encounter. 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.context w5: FiveWs.context v2: PV1 rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
effective[x]	Σ	0..1		There are no (further) constraints on this element Element id Observation.effective[x] Short description Clinically relevant time/time-period for observation Alternate names Occurrence Definition The time or time-period the observed value is asserted as being true. For biological subjects - e.g. human patients - this is usually called the "physiologically relevant time". This is usually either the time of the procedure or of specimen collection, but very often the source of the date/time is not known, only the date/time itself. Requirements Knowing when an observation was deemed true is important to its relevance as well as determining trends. Comments At least a date should be present unless this observation is a historical report. For recording imprecise or "fuzzy" times (For example, a blood glucose measurement taken "after breakfast") use the Timing datatype which allow the measurement to be tied to regular life events. 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: OBX-14, and/or OBX-19 after v2.4 (depends on who observation made) rim: effectiveTime
effectiveDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
effectivePeriod			Period	There are no (further) constraints on this element Data type Period
effectiveTiming			Timing	There are no (further) constraints on this element Data type Timing
effectiveInstant			instant	There are no (further) constraints on this element Data type instant
issued	S Σ	0..1	instant	Element id Observation.issued Short description Dokumentationsdatum Definition Zeitpunkt, an dem das Ergebnis der Laboruntersuchung dokumentiert wurde Comments For Observations that don’t require review and verification, it may be the same as the `lastUpdated` time of the resource itself. For Observations that do require review and verification for certain updates, it might not be the same as the `lastUpdated` time of the resource itself due to a non-clinically significant update that doesn’t require the new version to be reviewed and verified again. 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 (or MSH.7), or perhaps OBX-19 (depends on who observation made) rim: participation[typeCode=AUT].time
performer	Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element id Observation.performer Short description Who is responsible for the observation Definition Who was responsible for asserting the observed value as "true". Requirements May give a degree of confidence in the observation and also indicates where follow-up questions should be directed. 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(Practitioner \| PractitionerRole \| Organization \| CareTeam \| Patient \| RelatedPerson) 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: OBX.15 / (Practitioner) OBX-16, PRT-5:PRT-4='RO' / (Device) OBX-18 , PRT-10:PRT-4='EQUIP' / (Organization) OBX-23, PRT-8:PRT-4='PO' rim: participation[typeCode=PRF]
value[x]	S Σ I	0..1		Element id Observation.value[x] Short description Messwert Definition Wert der Analyse Requirements An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. Comments An observation may have; 1) a single value here, 2) both a value and a set of related or component values, or 3) only a set of related or component values. If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a sct-concept: < 441742003 \|Evaluation finding\| v2: OBX.2, OBX.5, OBX.6 rim: value sct-attr: 363714003 \|Interprets\|
valueQuantity			Quantity	There are no (further) constraints on this element Data type Quantity
valueCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
valueString			string	There are no (further) constraints on this element Data type string
valueBoolean			boolean	There are no (further) constraints on this element Data type boolean
valueInteger			integer	There are no (further) constraints on this element Data type integer
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
valueTime			time	There are no (further) constraints on this element Data type time
valueDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
valuePeriod			Period	There are no (further) constraints on this element Data type Period
dataAbsentReason	I	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Observation.dataAbsentReason Short description Why the result is missing Definition Provides a reason why the expected value in the element Observation.value[x] is missing. Requirements For many results it is necessary to handle exceptional values in measurements. Comments Null or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "specimen unsatisfactory". The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Note that an observation may only be reported if there are values to report. For example differential cell counts values may be reported only when > 0. Because of these options, use-case agreements are required to interpret general observations for null or exceptional values. Data type CodeableConcept Binding Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (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 rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: N/A rim: value.nullFlavor
interpretation		0..*	CodeableConceptBinding	There are no (further) constraints on this element Element id Observation.interpretation Short description High, low, normal, etc. Alternate names Abnormal Flag Definition A categorical assessment of an observation value. For example, high, low, normal. Requirements For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Comments Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Data type CodeableConcept Binding Codes identifying interpretations of observations. ObservationInterpretationCodes (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 rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD sct-concept: < 260245000 \|Findings values\| v2: OBX-8 rim: interpretationCode sct-attr: 363713009 \|Has interpretation\|
note		0..*	Annotation	There are no (further) constraints on this element Element id Observation.note Short description Comments about the observation Definition Comments about the observation or the results. Requirements Need to be able to provide free text additional information. Comments May include general statements about the observation, or statements about significant, unexpected or unreliable results values, or information about its source when relevant to its interpretation. Data type Annotation Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: N/A rim: Act v2: NTE.3 (partner NTE to OBX, or sometimes another (child?) OBX) rim: subjectOf.observationEvent[code="annotation"].value
bodySite	S	0..1	CodeableConcept	Element id Observation.bodySite Short description Anatomie Definition betrachtete Anatomie der Beobachtung Comments Only used if not implicit in code found in Observation.code. In many systems, this may be represented as a related observation instead of an inline component. If the use case requires BodySite to be handled as a separate resource (e.g. to identify and track separately) then use the standard extension bodySite. Data type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD sct-concept: < 123037004 \|Body structure\| v2: OBX-20 rim: targetSiteCode sct-attr: 718497002 \|Inherent location\|
method		0..1	CodeableConcept	There are no (further) constraints on this element Element id Observation.method Short description How it was done Definition Indicates the mechanism used to perform the observation. Requirements In some cases, method can impact results and is thus used for determining whether results can be compared or determining significance of results. Comments Only used if not implicit in code for Observation.code. Data type CodeableConcept Binding Methods for simple observations. ObservationMethods (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-17 rim: methodCode
specimen	I	0..1	Reference(Specimen)	There are no (further) constraints on this element Element id Observation.specimen Short description Specimen used for this observation Definition The specimen that was used when this observation was made. Comments Should only be used if not implicit in code found in `Observation.code`. Observations are not made on specimens themselves; they are made on a subject, but in many cases by the means of a specimen. Note that although specimens are often involved, they are not always tracked and reported explicitly. Also note that observation resources may be used in contexts that track the specimen explicitly (e.g. Diagnostic Report). 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) sct-concept: < 123038009 \|Specimen\| v2: SPM segment rim: participation[typeCode=SPC].specimen sct-attr: 704319004 \|Inherent in\|
device	I	0..1	Reference(Device \| DeviceMetric)	There are no (further) constraints on this element Element id Observation.device Short description (Measurement) Device Definition The device used to generate the observation data. Comments Note that this is not meant to represent a device involved in the transmission of the result, e.g., a gateway. Such devices may be documented using the Provenance resource where relevant. Data type Reference(Device \| DeviceMetric) 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) sct-concept: < 49062001 \|Device\| v2: OBX-17 / PRT -10 rim: participation[typeCode=DEV] sct-attr: 424226004 \|Using device\|
referenceRange	I	0..*	BackboneElement	There are no (further) constraints on this element Element id Observation.referenceRange Short description Provides guide for interpretation Definition Guidance on how to interpret the value by comparison to a normal or recommended range. Multiple reference ranges are interpreted as an "OR". In other words, to represent two distinct target populations, two `referenceRange` elements would be used. Requirements Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Comments Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` obs-3: Must have at least a low or a high or text `low.exists() or high.exists() or text.exists()` Mappings rim: n/a v2: OBX.7 rim: outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]
id		0..1	string	There are no (further) constraints on this element Element id Observation.referenceRange.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 Observation.referenceRange.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 Observation.referenceRange.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
low	I	0..1	SimpleQuantity	There are no (further) constraints on this element Element id Observation.referenceRange.low Short description Low Range, if relevant Definition The value of the low bound of the reference range. The low bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the low bound is omitted, it is assumed to be meaningless (e.g. reference range is <=2.3). Comments The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` qty-3: If a code for the unit is present, the system SHALL also be present `code.empty() or system.exists()` sqty-1: The comparator is not used on a SimpleQuantity `comparator.empty()` Mappings rim: n/a v2: SN (see also Range) or CQ rim: PQ, IVL<PQ>, MO, CO, depending on the values v2: OBX-7 rim: value:IVL_PQ.low
high	I	0..1	SimpleQuantity	There are no (further) constraints on this element Element id Observation.referenceRange.high Short description High Range, if relevant Definition The value of the high bound of the reference range. The high bound of the reference range endpoint is inclusive of the value (e.g. reference range is >=5 - <=9). If the high bound is omitted, it is assumed to be meaningless (e.g. reference range is >= 2.3). Comments The context of use may frequently define what kind of quantity this is and therefore what kind of units can be used. The context of use may also restrict the values for the comparator. Data type SimpleQuantity Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` qty-3: If a code for the unit is present, the system SHALL also be present `code.empty() or system.exists()` sqty-1: The comparator is not used on a SimpleQuantity `comparator.empty()` Mappings rim: n/a v2: SN (see also Range) or CQ rim: PQ, IVL<PQ>, MO, CO, depending on the values v2: OBX-7 rim: value:IVL_PQ.high
type		0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Observation.referenceRange.type Short description Reference range qualifier Definition Codes to indicate the what part of the targeted reference population it applies to. For example, the normal or therapeutic range. Requirements Need to be able to say what kind of reference range this is - normal, recommended, therapeutic, etc., - for proper interpretation. Comments This SHOULD be populated if there is more than one range. If this element is not present then the normal range is assumed. Data type CodeableConcept Binding Code for the meaning of a reference range. ObservationReferenceRangeMeaningCodes (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 sct-concept: < 260245000 \|Findings values\| OR < 365860008 \|General clinical state finding\| OR < 250171008 \|Clinical history or observation findings\| OR < 415229000 \|Racial group\| OR < 365400002 \|Finding of puberty stage\| OR < 443938003 \|Procedure carried out on subject\| v2: OBX-10 rim: interpretationCode
appliesTo		0..*	CodeableConcept	There are no (further) constraints on this element Element id Observation.referenceRange.appliesTo Short description Reference range population Definition Codes to indicate the target population this reference range applies to. For example, a reference range may be based on the normal population or a particular sex or race. Multiple `appliesTo` are interpreted as an "AND" of the target populations. For example, to represent a target population of African American females, both a code of female and a code for African American would be used. Requirements Need to be able to identify the target population for proper interpretation. Comments This SHOULD be populated if there is more than one range. If this element is not present then the normal population is assumed. Data type CodeableConcept Binding Codes identifying the population the reference range applies to. ObservationReferenceRangeAppliesToCodes (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 sct-concept: < 260245000 \|Findings values\| OR < 365860008 \|General clinical state finding\| OR < 250171008 \|Clinical history or observation findings\| OR < 415229000 \|Racial group\| OR < 365400002 \|Finding of puberty stage\| OR < 443938003 \|Procedure carried out on subject\| v2: OBX-10 rim: interpretationCode
age	I	0..1	Range	There are no (further) constraints on this element Element id Observation.referenceRange.age Short description Applicable age range, if relevant Definition The age at which this reference range is applicable. This is a neonatal age (e.g. number of weeks at term) if the meaning says so. Requirements Some analytes vary greatly over age. Comments The stated low and high value are assumed to have arbitrarily high precision when it comes to determining which values are in the range. I.e. 1.99 is not in the range 2 -> 3. Data type Range Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` rng-2: If present, low SHALL have a lower value than high `low.empty() or high.empty() or (low <= high)` Mappings rim: n/a v2: NR and also possibly SN (but see also quantity) rim: IVL<QTY[not(type="TS")]> [lowClosed="true" and highClosed="true"]or URG<QTY[not(type="TS")]> rim: outboundRelationship[typeCode=PRCN].targetObservationCriterion[code="age"].value
text		0..1	string	There are no (further) constraints on this element Element id Observation.referenceRange.text Short description Text based reference range in an observation Definition Text based reference range in an observation which may be used when a quantitative range is not appropriate for an observation. An example would be a reference value of "Negative" or a list or table of "normals". 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-7 rim: value:ST
hasMember	S Σ I	0..*	Reference(Observation)	Element id Observation.hasMember Short description weitere Beobachtungen Definition Referenzierung weiterer Beobachtungen Comments When using this element, an observation will typically have either a value or a set of related resources, although both may be present in some cases. For a discussion on the ways Observations can assembled in groups together, see Notes below. Note that a system may calculate results from QuestionnaireResponse into a final score and represent the score as an Observation. 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: Relationships established by OBX-4 usage rim: outBoundRelationship
derivedFrom	S Σ I	0..*	Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence)	Element id Observation.derivedFrom Short description abgeleitet Definition Abgeleitet von ImagingStudy, ect. Comments All the reference choices that are listed in this element can represent clinical observations and other measurements that may be the source for a derived value. The most common reference will be another Observation. For a discussion on the ways Observations can assembled in groups together, see Notes below. Data type Reference(DocumentReference \| ImagingStudy \| Media \| QuestionnaireResponse \| Observation \| MolecularSequence) 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: Relationships established by OBX-4 usage rim: .targetObservation
component	S Σ	0..*	BackboneElement	Element id Observation.component Short description Bestandteile Definition detailierte Bestandteile der Beobachtung Requirements Component observations share the same attributes in the Observation resource as the primary observation and are always treated a part of a single observation (they are not separable). However, the reference range for the primary observation value is not inherited by the component values and is required when appropriate for each component observation. Comments For a discussion on the ways Observations can be assembled in groups together see Notes below. 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: containment by OBX-4? rim: outBoundRelationship[typeCode=COMP]
id		0..1	string	There are no (further) constraints on this element Element id Observation.component.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 Observation.component.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 Observation.component.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
code	Σ	1..1	CodeableConcept	There are no (further) constraints on this element Element id Observation.component.code Short description Type of component observation (code / type) Definition Describes what was observed. Sometimes this is called the observation "code". Requirements Knowing what kind of observation is being made is essential to understanding the observation. Comments All code-value and component.code-component.value pairs need to be taken into account to correctly understand the meaning of the observation. Data type CodeableConcept Binding Codes identifying names of simple observations. LOINCCodes (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.what[x] sct-concept: < 363787002 \|Observable entity\| OR < 386053000 \|Evaluation procedure\| v2: OBX-3 rim: code
value[x]	Σ	0..1		There are no (further) constraints on this element Element id Observation.component.value[x] Short description Actual component result Definition The information determined as a result of making the observation, if the information has a simple value. Requirements An observation exists to have a value, though it might not if it is in error, or if it represents a group of observations. Comments Used when observation has a set of component observations. An observation may have both a value (e.g. an Apgar score) and component observations (the observations from which the Apgar score was derived). If a value is present, the datatype for this element should be determined by Observation.code. A CodeableConcept with just a text would be used instead of a string if the field was usually coded, or if the type associated with the Observation.code defines a coded value. For additional guidance, see the Notes section below. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a sct-concept: 363714003 \|Interprets\| < 441742003 \|Evaluation finding\| v2: OBX.2, OBX.5, OBX.6 rim: value sct-attr: 363714003 \|Interprets\|
valueQuantity			Quantity	There are no (further) constraints on this element Data type Quantity
valueCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data type CodeableConcept
valueString			string	There are no (further) constraints on this element Data type string
valueBoolean			boolean	There are no (further) constraints on this element Data type boolean
valueInteger			integer	There are no (further) constraints on this element Data type integer
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
valueTime			time	There are no (further) constraints on this element Data type time
valueDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
valuePeriod			Period	There are no (further) constraints on this element Data type Period
dataAbsentReason	I	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id Observation.component.dataAbsentReason Short description Why the component result is missing Definition Provides a reason why the expected value in the element Observation.component.value[x] is missing. Requirements For many results it is necessary to handle exceptional values in measurements. Comments "Null" or exceptional values can be represented two ways in FHIR Observations. One way is to simply include them in the value set and represent the exceptions in the value. For example, measurement values for a serology test could be "detected", "not detected", "inconclusive", or "test not done". The alternate way is to use the value element for actual observations and use the explicit dataAbsentReason element to record exceptional values. For example, the dataAbsentReason code "error" could be used when the measurement was not completed. Because of these options, use-case agreements are required to interpret general observations for exceptional values. Data type CodeableConcept Binding Codes specifying why the result (`Observation.value[x]`) is missing. DataAbsentReason (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 rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: N/A rim: value.nullFlavor
interpretation		0..*	CodeableConceptBinding	There are no (further) constraints on this element Element id Observation.component.interpretation Short description High, low, normal, etc. Alternate names Abnormal Flag Definition A categorical assessment of an observation value. For example, high, low, normal. Requirements For some results, particularly numeric results, an interpretation is necessary to fully understand the significance of a result. Comments Historically used for laboratory results (known as 'abnormal flag' ), its use extends to other use cases where coded interpretations are relevant. Often reported as one or more simple compact codes this element is often placed adjacent to the result value in reports and flow sheets to signal the meaning/normalcy status of the result. Data type CodeableConcept Binding Codes identifying interpretations of observations. ObservationInterpretationCodes (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 rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD sct-concept: < 260245000 \|Findings values\| v2: OBX-8 rim: interpretationCode sct-attr: 363713009 \|Has interpretation\|
referenceRange		0..*	see (referenceRange)	There are no (further) constraints on this element Element id Observation.component.referenceRange Short description Provides guide for interpretation of component result Definition Guidance on how to interpret the value by comparison to a normal or recommended range. Requirements Knowing what values are considered "normal" can help evaluate the significance of a particular result. Need to be able to provide multiple reference ranges for different contexts. Comments Most observations only have one generic reference range. Systems MAY choose to restrict to only supplying the relevant reference range based on knowledge about the patient (e.g., specific to the patient's age, gender, weight and other factors), but this might not be possible or appropriate. Whenever more than one reference range is supplied, the differences between them SHOULD be provided in the reference range and/or age properties. Mappings v2: OBX.7 rim: outboundRelationship[typeCode=REFV]/target[classCode=OBS, moodCode=EVN]

Dieses Profil beschreibt den Befund/eine Beobachtung in der radiologischer Bildgebung. Es bietet die Möglichkeit strukturiert Beobachtungen abzubilden und den Befundbericht zu ergänzen.

Feldname	Kurzbeschreibung
Observation.id
Observation.meta
Observation.meta.source
Observation.meta.profile
Observation.extension:bodyStructure	Körperstruktur
Observation.partOf	Teil von
Observation.status	Status
Observation.category	Kategorie
Observation.code	Code
Observation.subject	Person
Observation.issued	Dokumentationsdatum
Observation.value[x]	Messwert
Observation.bodySite	Anatomie
Observation.hasMember	weitere Beobachtungen
Observation.derivedFrom	abgeleitet
Observation.component	Bestandteile

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-bildgebung-radiologische-beobachtung" />
    <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-radiologische-beobachtung" />
    <version value="2025.0.0" />
    <name value="MII_PR_Bildgebung_Radiologische_Beobachtung">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII_PR_Imaging_Radiological_Observation" />
            </extension>
        </extension>
    </name>
    <title value="MII PR Bildgebung Radiologische Beobachtung">
        <extension url="http://hl7.org/fhir/StructureDefinition/translation">
            <extension url="lang">
                <valueCode value="en-US" />
            </extension>
            <extension url="content">
                <valueString value="MII PR Imaging Radiological Observation" />
            </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 beschreibt den Befund/eine Beobachtung in der radiologischer Bildgebung. Es bietet die M&#246;glichkeit strukturiert Beobachtungen abzubilden und den Befundbericht zu erg&#228;nzen.">
        <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 observation for radiological images." />
            </extension>
        </extension>
    </description>
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="Observation" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/Observation" />
    <derivation value="constraint" />
    <differential>
        <element id="Observation.id">
            <path value="Observation.id" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.meta">
            <path value="Observation.meta" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.meta.source">
            <path value="Observation.meta.source" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.meta.profile">
            <path value="Observation.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="Observation.extension">
            <path value="Observation.extension" />
            <slicing>
                <discriminator>
                    <type value="value" />
                    <path value="url" />
                </discriminator>
                <ordered value="false" />
                <rules value="open" />
            </slicing>
        </element>
        <element id="Observation.extension:SeriesUID">
            <path value="Observation.extension" />
            <sliceName value="SeriesUID" />
            <short value="Serien UID">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Serien UID" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Series UID" />
                    </extension>
                </extension>
            </short>
            <definition value="UID einer DICOM-Serie">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="UID einer DICOM-Serie" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="UID of a series" />
                    </extension>
                </extension>
            </definition>
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-series-uid" />
            </type>
        </element>
        <element id="Observation.extension:SOPInstanzUID">
            <path value="Observation.extension" />
            <sliceName value="SOPInstanzUID" />
            <short value="SOP Instanz UID">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="SOP Instanz UID" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="SOP Instance UID" />
                    </extension>
                </extension>
            </short>
            <definition value="UID einer SOP Instanz">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="UID einer SOP Instanz" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="UID of a SOP instance" />
                    </extension>
                </extension>
            </definition>
            <min value="0" />
            <max value="1" />
            <type>
                <code value="Extension" />
                <profile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-sop-instanz-uid" />
            </type>
        </element>
        <element id="Observation.extension:bodyStructure">
            <path value="Observation.extension" />
            <sliceName value="bodyStructure" />
            <short value="K&#246;rperstruktur">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="K&#246;rperstruktur" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="body structure" />
                    </extension>
                </extension>
            </short>
            <definition value="Referenz auf eine K&#246;rperstruktur">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Referenz auf eine K&#246;rperstruktur" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="reference on a body structure" />
                    </extension>
                </extension>
            </definition>
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Extension" />
                <profile value="http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Observation.extension:bodyStructure.value[x]">
            <path value="Observation.extension.value[x]" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-koerperstruktur" />
            </type>
        </element>
        <element id="Observation.partOf">
            <path value="Observation.partOf" />
            <short value="Teil von">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Teil von" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="part of" />
                    </extension>
                </extension>
            </short>
            <definition value="Teil einer Befundungprozedur">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Teil einer Befundungprozedur" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="part of a read procedure" />
                    </extension>
                </extension>
            </definition>
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Observation.status">
            <path value="Observation.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 | vorl&#228;ufig | endg&#252;ltig | ge&#228;ndert | korrigiert | 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 | vorl&#228;ufig | endg&#252;ltig | ge&#228;ndert | korrigiert | 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 | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.category">
            <path value="Observation.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="Klassifikation in diagnostischen Fachbereich und Gruppe">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Klassifikation in diagnostischen Fachbereich und Gruppe" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Classification of the diagnostic service section" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.code">
            <path value="Observation.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="Ein Code f&#252;r die zu befundende Beoabchtung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Ein Code f&#252;r die zu befundende Beoabchtung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="A code identifying the inspected observation" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.subject">
            <path value="Observation.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 Beobachtung 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 Beobachtung 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 observation 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="Observation.issued">
            <path value="Observation.issued" />
            <short value="Dokumentationsdatum">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Dokumentationsdatum" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Issued" />
                    </extension>
                </extension>
            </short>
            <definition value="Zeitpunkt, an dem das Ergebnis der Laboruntersuchung dokumentiert wurde">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Zeitpunkt, an dem das Ergebnis der Laboruntersuchung dokumentiert wurde" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="The point in time when the laboratory result was documented" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.value[x]">
            <path value="Observation.value[x]" />
            <short value="Messwert">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Messwert" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Value" />
                    </extension>
                </extension>
            </short>
            <definition value="Wert der Analyse">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Wert der Analyse" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="Value of the analysis" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.bodySite">
            <path value="Observation.bodySite" />
            <short value="Anatomie">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Anatomie" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="body site" />
                    </extension>
                </extension>
            </short>
            <definition value="betrachtete Anatomie der Beobachtung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="betrachtete Anatomie der Beobachtung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="inspected body site in this observation" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.hasMember">
            <path value="Observation.hasMember" />
            <short value="weitere Beobachtungen">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="weitere Beobachtungen" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="additional observation" />
                    </extension>
                </extension>
            </short>
            <definition value="Referenzierung weiterer Beobachtungen">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Referenzierung weiterer Beobachtungen" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="reference on additional observations" />
                    </extension>
                </extension>
            </definition>
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Observation" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="Observation.derivedFrom">
            <path value="Observation.derivedFrom" />
            <short value="abgeleitet">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="abgeleitet" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="derived from" />
                    </extension>
                </extension>
            </short>
            <definition value="Abgeleitet von ImagingStudy, ect.">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Abgeleitet von ImagingStudy, ect." />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="derived from an imagingStud, etc." />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
        <element id="Observation.component">
            <path value="Observation.component" />
            <short value="Bestandteile">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="Bestandteile" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="components" />
                    </extension>
                </extension>
            </short>
            <definition value="detailierte Bestandteile der Beobachtung">
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="de-DE" />
                    </extension>
                    <extension url="content">
                        <valueString value="detailierte Bestandteile der Beobachtung" />
                    </extension>
                </extension>
                <extension url="http://hl7.org/fhir/StructureDefinition/translation">
                    <extension url="lang">
                        <valueCode value="en-US" />
                    </extension>
                    <extension url="content">
                        <valueString value="detailed components of this observation" />
                    </extension>
                </extension>
            </definition>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-bildgebung-radiologische-beobachtung",
    "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-radiologische-beobachtung",
    "version": "2025.0.0",
    "name": "MII_PR_Bildgebung_Radiologische_Beobachtung",
    "_name": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII_PR_Imaging_Radiological_Observation"
                    }
                ]
            }
        ]
    },
    "title": "MII PR Bildgebung Radiologische Beobachtung",
    "_title": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "MII PR Imaging Radiological Observation"
                    }
                ]
            }
        ]
    },
    "status": "active",
    "date": "2025-01-01",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Dieses Profil beschreibt den Befund/eine Beobachtung in der radiologischer Bildgebung. Es bietet die Möglichkeit strukturiert Beobachtungen abzubilden und den Befundbericht zu ergänzen.",
    "_description": {
        "extension":  [
            {
                "url": "http://hl7.org/fhir/StructureDefinition/translation",
                "extension":  [
                    {
                        "url": "lang",
                        "valueCode": "en-US"
                    },
                    {
                        "url": "content",
                        "valueString": "The profile describes a observation for radiological images."
                    }
                ]
            }
        ]
    },
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "Observation",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/Observation",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "Observation.id",
                "path": "Observation.id",
                "mustSupport": true
            },
            {
                "id": "Observation.meta",
                "path": "Observation.meta",
                "mustSupport": true
            },
            {
                "id": "Observation.meta.source",
                "path": "Observation.meta.source",
                "mustSupport": true
            },
            {
                "id": "Observation.meta.profile",
                "path": "Observation.meta.profile",
                "mustSupport": true
            },
            {
                "id": "Observation.extension",
                "path": "Observation.extension",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "value",
                            "path": "url"
                        }
                    ],
                    "ordered": false,
                    "rules": "open"
                }
            },
            {
                "id": "Observation.extension:SeriesUID",
                "path": "Observation.extension",
                "sliceName": "SeriesUID",
                "short": "Serien UID",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Serien UID"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Series UID"
                                }
                            ]
                        }
                    ]
                },
                "definition": "UID einer DICOM-Serie",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "UID einer DICOM-Serie"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "UID of a series"
                                }
                            ]
                        }
                    ]
                },
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-series-uid"
                        ]
                    }
                ]
            },
            {
                "id": "Observation.extension:SOPInstanzUID",
                "path": "Observation.extension",
                "sliceName": "SOPInstanzUID",
                "short": "SOP Instanz UID",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "SOP Instanz UID"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "SOP Instance UID"
                                }
                            ]
                        }
                    ]
                },
                "definition": "UID einer SOP Instanz",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "UID einer SOP Instanz"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "UID of a SOP instance"
                                }
                            ]
                        }
                    ]
                },
                "min": 0,
                "max": "1",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-sop-instanz-uid"
                        ]
                    }
                ]
            },
            {
                "id": "Observation.extension:bodyStructure",
                "path": "Observation.extension",
                "sliceName": "bodyStructure",
                "short": "Körperstruktur",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Körperstruktur"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "body structure"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Referenz auf eine Körperstruktur",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Referenz auf eine Körperstruktur"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "reference on a body structure"
                                }
                            ]
                        }
                    ]
                },
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Extension",
                        "profile":  [
                            "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Observation.extension:bodyStructure.value[x]",
                "path": "Observation.extension.value[x]",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-koerperstruktur"
                        ]
                    }
                ]
            },
            {
                "id": "Observation.partOf",
                "path": "Observation.partOf",
                "short": "Teil von",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Teil von"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "part of"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Teil einer Befundungprozedur",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Teil einer Befundungprozedur"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "part of a read procedure"
                                }
                            ]
                        }
                    ]
                },
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-befundungsprozedur"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Observation.status",
                "path": "Observation.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 | vorläufig | endgültig | geändert | korrigiert | abgebrochen | fehlerhafte Eingabe | unbekannt",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "angemeldet | vorläufig | endgültig | geändert | korrigiert | abgebrochen | fehlerhafte Eingabe | unbekannt"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "registered | preliminary | final | amended | corrected | cancelled | entered-in-error | unknown"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.category",
                "path": "Observation.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": "Klassifikation in diagnostischen Fachbereich und Gruppe",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Klassifikation in diagnostischen Fachbereich und Gruppe"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Classification of the diagnostic service section"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.code",
                "path": "Observation.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": "Ein Code für die zu befundende Beoabchtung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Ein Code für die zu befundende Beoabchtung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "A code identifying the inspected observation"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.subject",
                "path": "Observation.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 Beobachtung bezieht",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Person, auf die sich die Beobachtung bezieht"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "person, which this observation is about"
                                }
                            ]
                        }
                    ]
                },
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Observation.issued",
                "path": "Observation.issued",
                "short": "Dokumentationsdatum",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Dokumentationsdatum"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Issued"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Zeitpunkt, an dem das Ergebnis der Laboruntersuchung dokumentiert wurde",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Zeitpunkt, an dem das Ergebnis der Laboruntersuchung dokumentiert wurde"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "The point in time when the laboratory result was documented"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.value[x]",
                "path": "Observation.value[x]",
                "short": "Messwert",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Messwert"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Value"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Wert der Analyse",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Wert der Analyse"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Value of the analysis"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.bodySite",
                "path": "Observation.bodySite",
                "short": "Anatomie",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Anatomie"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "body site"
                                }
                            ]
                        }
                    ]
                },
                "definition": "betrachtete Anatomie der Beobachtung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "betrachtete Anatomie der Beobachtung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "inspected body site in this observation"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.hasMember",
                "path": "Observation.hasMember",
                "short": "weitere Beobachtungen",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "weitere Beobachtungen"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "additional observation"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Referenzierung weiterer Beobachtungen",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Referenzierung weiterer Beobachtungen"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "reference on additional observations"
                                }
                            ]
                        }
                    ]
                },
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Observation"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "Observation.derivedFrom",
                "path": "Observation.derivedFrom",
                "short": "abgeleitet",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "abgeleitet"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "derived from"
                                }
                            ]
                        }
                    ]
                },
                "definition": "Abgeleitet von ImagingStudy, ect.",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Abgeleitet von ImagingStudy, ect."
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "derived from an imagingStud, etc."
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            },
            {
                "id": "Observation.component",
                "path": "Observation.component",
                "short": "Bestandteile",
                "_short": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "Bestandteile"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "components"
                                }
                            ]
                        }
                    ]
                },
                "definition": "detailierte Bestandteile der Beobachtung",
                "_definition": {
                    "extension":  [
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "de-DE"
                                },
                                {
                                    "url": "content",
                                    "valueString": "detailierte Bestandteile der Beobachtung"
                                }
                            ]
                        },
                        {
                            "url": "http://hl7.org/fhir/StructureDefinition/translation",
                            "extension":  [
                                {
                                    "url": "lang",
                                    "valueCode": "en-US"
                                },
                                {
                                    "url": "content",
                                    "valueString": "detailed components of this observation"
                                }
                            ]
                        }
                    ]
                },
                "mustSupport": true
            }
        ]
    }
}

MII PR Bildgebung Radiologische Beobachtung

FHIR	Datensatz	Erklaerung
Observation	Bildgebung.GenerischeBeobachtung	Befundabschnitt des semistrukturierten Befunddokuments.
Observation.extension(https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-serie-uid)	Bildgebung.GenerischeBeobachtung.Bildnummer	DICOM Series UID der zugehörigen Serie.
Observation.extension(https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-sop-instanz-uid)	Bildgebung.GenerischeBeobachtung.Schichtposition	DICOM Instance UID der zugehörigen SOP Instance.
Observation.extension(https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-observation-imaging)	Bildgebung.GenerischeBeobachtung.ErweiterteKoerperstruktur	Backport der R5 Referenz auf das BodyStructure-Profil.
Observation.partOf	Bildgebung.GenerischeBeobachtung.TeilEinerBefundungsprozedur	Hier soll auf das MII KDS-Modul Prozedur referenziert werden
Observation.status	Bildgebung.GenerischeBeobachtung.Status	Status der Beobachtung.
Observation.category	Bildgebung.GenerischeBeobachtung.Beobachtungsklassifizierung	Klassifiziert eine Beobachtung
Observation.code	Bildgebung.GenerischeBeobachtung.Beobachtungstyp	Typ der Beobachtung.
Observation.subject	Bildgebung.GenerischeBeobachtung.Person	Person, auf die sich die Beobachtung bezieht. Hier soll das MII KDS-Modul Person verwendet werden.
Observation.issued	Bildgebung.GenerischeBeobachtung.Beobachtungszeitpunkt	Zeitpunkt an dem die Beobachtung gemacht wird.
Observation.value[x]	Bildgebung.GenerischeBeobachtung.Beschreibung	Detaillierte Beschreibung der Beobachtung mit value[x].
Observation.bodySite	Bildgebung.GenerischeBeobachtung.Koerperregion	Codierte Körperregion der Beobachtung
Observation.hasMember	Bildgebung.GenerischeBeobachtung.WeitereBeobachtung	Weitere Beobachtung(en) als Referenz auf weitere Observation(s).
Obervation.derivedFrom	Bildgebung.GenerischeBeobachtung.Studienbezug	Bezug auf die zugehörige(n) Bildgebungsstudie(n).
Observation.component	Bildgebung.GenerischeBeobachtung.ErweiterteBeschreibung	Kann mehrere Beschreibungen strukturiert abbilden.

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
series-uid	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-observation-series-uid	token	SHALL
sop-instance-uid	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-observation-sop-instance-uid	token	SHALL
body-structure	https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/SearchParameter/mii-sp-bildgebung-observation-body-structure	reference	SHALL
part-of	http://hl7.org/fhir/SearchParameter/Observation-part-of	reference	SHALL
status	http://hl7.org/fhir/SearchParameter/Observation-status	token	SHALL
category	http://hl7.org/fhir/SearchParameter/Observation-category	token	SHALL
code	http://hl7.org/fhir/SearchParameter/clinical-code	token	SHALL
patient	http://hl7.org/fhir/SearchParameter/clinical-patient	reference	SHALL
issued	https://www.medizininformatik-initiative.de/fhir/modul-meta/SearchParameter/mii-sp-meta-observation-issued	date	SHALL
value-concept	http://hl7.org/fhir/SearchParameter/Observation-value-concept	token	SHALL
value-date	http://hl7.org/fhir/SearchParameter/Observation-value-date	date	SHALL
value-quantity	http://hl7.org/fhir/SearchParameter/Observation-value-quantity	quantity	SHALL
value-string	http://hl7.org/fhir/SearchParameter/Observation-value-string	string	SHALL
body-site	https://www.medizininformatik-initiative.de/fhir/modul-meta/SearchParameter/mii-sp-meta-observation-bodysite	token	SHALL
has-member	http://hl7.org/fhir/SearchParameter/Observation-has-member	reference	SHALL
derived-from	http://hl7.org/fhir/SearchParameter/Observation-derived-from	reference	SHALL
code-value-concept	http://hl7.org/fhir/SearchParameter/Observation-code-value-concept	composite	SHALL
code-value-date	http://hl7.org/fhir/SearchParameter/Observation-code-value-date	composite	SHALL
code-value-quantity	http://hl7.org/fhir/SearchParameter/Observation-code-value-quantity	composite	SHALL
code-value-string	http://hl7.org/fhir/SearchParameter/Observation-code-value-string	composite	SHALL
combo-code	http://hl7.org/fhir/SearchParameter/Observation-combo-code	token	SHALL
combo-code-value-concept	http://hl7.org/fhir/SearchParameter/Observation-combo-code-value-concept	composite	SHALL
combo-code-value-quantity	http://hl7.org/fhir/SearchParameter/Observation-combo-code-value-quantity	composite	SHALL
combo-value-concept	http://hl7.org/fhir/SearchParameter/Observation-combo-value-concept	token	SHALL
combo-value-quantity	http://hl7.org/fhir/SearchParameter/Observation-combo-value-quantity	quantity	SHALL
component-code	http://hl7.org/fhir/SearchParameter/Observation-component-code	token	SHALL
component-code-value-concept	http://hl7.org/fhir/SearchParameter/Observation-component-code-value-concept	composite	SHALL
component-code-value-quantity	http://hl7.org/fhir/SearchParameter/Observation-component-code-value-quantity	composite	SHALL
component-value-concept	http://hl7.org/fhir/SearchParameter/Observation-component-value-concept	token	SHALL
component-value-quantity	http://hl7.org/fhir/SearchParameter/Observation-component-value-quantity	quantity	SHALL

Beispiele

Beispiel einer Observation-Ressource zur strukturierten Darstellung eine radiologischen Beobachtung:

{
    "resourceType": "Observation",
    "id": "mii-exa-bildgebung-radiologische-beobachtung",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologische-beobachtung"
        ]
    },
    "extension":  [
        {
            "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-series-uid",
            "valueId": "example-series-uid"
        },
        {
            "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-ex-bildgebung-sop-instanz-uid",
            "valueId": "example-sop-instance-uid"
        },
        {
            "url": "http://hl7.org/fhir/5.0/StructureDefinition/extension-Observation.bodyStructure",
            "valueReference": {
                "reference": "BodyStructure/mii-exa-bildgebung-koerperstruktur"
            }
        }
    ],
    "partOf":  [
        {
            "reference": "Procedure/mii-exa-bildgebung-radiologische-befundungsprozedur"
        }
    ],
    "status": "final",
    "category":  [
        {
            "coding":  [
                {
                    "code": "imaging",
                    "system": "http://terminology.hl7.org/CodeSystem/observation-category",
                    "display": "Imaging"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "32422-8",
                "system": "http://loinc.org",
                "display": "Physical findings of Breast"
            }
        ]
    },
    "subject": {
        "reference": "Patient/PatExample"
    },
    "issued": "2024-07-19T12:03:30+02:00",
    "valueString": "microcalcifications in the upper outer quadrant in the left breast",
    "bodySite": {
        "coding":  [
            {
                "code": "76752008",
                "system": "http://snomed.info/sct",
                "display": "Breast structure (body structure)"
            }
        ]
    },
    "hasMember":  [
        {
            "reference": "Observation/ObsExample"
        }
    ],
    "derivedFrom":  [
        {
            "reference": "ImagingStudy/mii-exa-bildgebung-bildgebungsstudie-ct"
        }
    ],
    "component":  [
        {
            "code": {
                "coding":  [
                    {
                        "code": "10157-6",
                        "system": "http://loinc.org",
                        "display": "History of family member diseases Narrative"
                    }
                ]
            },
            "valueBoolean": true
        }
    ]
}