Dieses Profil beschreibt einen Pathologie-Befund im Rahmen in der Onkologie.
Da die Daten aus den lokalen Tumordokumentationssystemen stammen, wird ein Großteil der Befunde in reiner Textform vorliegen.
Die Pathologie-Befundung KANN im Rahmen der MII ebenfalls über den Pathologie-Befundbericht erfolgen. In dem Fall können einzelne Beobachtung als Patho Findings über LOINC oder SNOMED strukturiert codiert werden. https://www.medizininformatik-initiative.de/Kerndatensatz/Modul_Pathologie_Befund/MII-IG-KDS-Modul-Pathologie-Befund-TechnischeImplementierung-FHIRProfile-MII-PR-Patho-Report.html
Name | Status | Version | Canonical | Basis |
---|---|---|---|---|
MII_PR_Onko_Befund | draft | 2024.0.0-ballot | https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund | http://hl7.org/fhir/StructureDefinition/DiagnosticReport |
MII_PR_Onko_Befund (DiagnosticReport) | I | DiagnosticReport | |
id | Σ | 0..1 | string |
meta | Σ | 0..1 | Meta |
id | 0..1 | string | |
extension | I | 0..* | Extension |
versionId | Σ | 0..1 | id |
lastUpdated | Σ | 0..1 | instant |
source | Σ | 0..1 | uri |
profile | S Σ | 0..* | canonical(StructureDefinition) |
security | Σ | 0..* | CodingBinding |
tag | Σ | 0..* | Coding |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | I | 0..* | Extension |
modifierExtension | ?! I | 0..* | Extension |
identifier | Σ | 0..* | Identifier |
basedOn | S I | 0..* | Reference(MII_PR_Onko_Tumorkonferenz | CarePlan) |
status | Σ ?! | 1..1 | codeBinding |
category | Σ | 0..* | CodeableConcept |
code | S Σ | 1..1 | CodeableConceptBinding |
id | 0..1 | string | |
extension | I | 0..* | Extension |
coding | S Σ | 1..* | Coding |
pathology-report | S Σ | 1..1 | CodingPattern |
id | 0..1 | string | |
extension | I | 0..* | Extension |
system | S Σ | 1..1 | uriPattern |
version | Σ | 0..1 | string |
code | S Σ | 1..1 | codePattern |
display | Σ | 0..1 | string |
userSelected | Σ | 0..1 | boolean |
text | Σ | 0..1 | string |
subject | S Σ I | 1..1 | Reference(Patient) |
encounter | S Σ I | 0..1 | Reference(Encounter) |
effective[x] | Σ | 0..1 | |
effectiveDateTime | dateTime | ||
effectivePeriod | Period | ||
issued | Σ | 0..1 | instant |
performer | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) |
resultsInterpreter | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) |
specimen | S I | 0..* | Reference(MII_PR_Onko_Specimen | Specimen) |
result | I | 0..* | Reference(Observation) |
imagingStudy | I | 0..* | Reference(ImagingStudy) |
media | Σ | 0..* | BackboneElement |
id | 0..1 | string | |
extension | I | 0..* | Extension |
modifierExtension | Σ ?! I | 0..* | Extension |
comment | 0..1 | string | |
link | Σ I | 1..1 | Reference(Media) |
conclusion | S | 1..1 | string |
conclusionCode | 0..* | CodeableConcept | |
presentedForm | I | 0..* | Attachment |
Histologie: Befund. Vollständiger Befundbericht des Pathologen. |
Feldname | Kurzbeschreibung |
---|---|
DiagnosticReport.meta.profile | |
DiagnosticReport.basedOn | |
DiagnosticReport.code | Pathology report code |
DiagnosticReport.code.coding | |
DiagnosticReport.code.coding:pathology-report | |
DiagnosticReport.code.coding:pathology-report.system | |
DiagnosticReport.code.coding:pathology-report.code | |
DiagnosticReport.subject | |
DiagnosticReport.encounter | |
DiagnosticReport.specimen | |
DiagnosticReport.conclusion |
<StructureDefinition xmlns="http://hl7.org/fhir"> <id value="mii-pr-onko-befund" /> <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund" /> <version value="2024.0.0-ballot" /> <name value="MII_PR_Onko_Befund" /> <title value="MII PR Onkologie Befund" /> <status value="draft" /> <publisher value="Medizininformatik Initiative" /> <contact> <telecom> <system value="url" /> <value value="https://www.medizininformatik-initiative.de" /> </telecom> </contact> <description value="Histologie: Befund. Vollständiger Befundbericht des Pathologen." /> <fhirVersion value="4.0.1" /> <mapping> <identity value="oBDS" /> <name value="Mapping FHIR zu oBDS" /> </mapping> <kind value="resource" /> <abstract value="false" /> <type value="DiagnosticReport" /> <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" /> <derivation value="constraint" /> <differential> <element id="DiagnosticReport.meta.profile"> <path value="DiagnosticReport.meta.profile" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.basedOn"> <path value="DiagnosticReport.basedOn" /> <type> <code value="Reference" /> <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/CarePlan" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.code"> <path value="DiagnosticReport.code" /> <short value="Pathology report code" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.code.coding"> <path value="DiagnosticReport.code.coding" /> <slicing> <discriminator> <type value="pattern" /> <path value="$this" /> </discriminator> <rules value="open" /> </slicing> <min value="1" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.code.coding:pathology-report"> <path value="DiagnosticReport.code.coding" /> <sliceName value="pathology-report" /> <min value="1" /> <max value="1" /> <patternCoding> <system value="http://loinc.org" /> <code value="60568-3" /> </patternCoding> <mustSupport value="true" /> </element> <element id="DiagnosticReport.code.coding:pathology-report.system"> <path value="DiagnosticReport.code.coding.system" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.code.coding:pathology-report.code"> <path value="DiagnosticReport.code.coding.code" /> <min value="1" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.subject"> <path value="DiagnosticReport.subject" /> <min value="1" /> <type> <code value="Reference" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.encounter"> <path value="DiagnosticReport.encounter" /> <mustSupport value="true" /> </element> <element id="DiagnosticReport.specimen"> <path value="DiagnosticReport.specimen" /> <type> <code value="Reference" /> <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen" /> <targetProfile value="http://hl7.org/fhir/StructureDefinition/Specimen" /> </type> <mustSupport value="true" /> </element> <element id="DiagnosticReport.conclusion"> <path value="DiagnosticReport.conclusion" /> <min value="1" /> <mustSupport value="true" /> <mapping> <identity value="oBDS" /> <map value="6.11" /> <comment value="Befund" /> </mapping> </element> </differential> </StructureDefinition>
{ "resourceType": "StructureDefinition", "id": "mii-pr-onko-befund", "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund", "version": "2024.0.0-ballot", "name": "MII_PR_Onko_Befund", "title": "MII PR Onkologie Befund", "status": "draft", "publisher": "Medizininformatik Initiative", "contact": [ { "telecom": [ { "system": "url", "value": "https://www.medizininformatik-initiative.de" } ] } ], "description": "Histologie: Befund. Vollständiger Befundbericht des Pathologen.", "fhirVersion": "4.0.1", "mapping": [ { "identity": "oBDS", "name": "Mapping FHIR zu oBDS" } ], "kind": "resource", "abstract": false, "type": "DiagnosticReport", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "derivation": "constraint", "differential": { "element": [ { "id": "DiagnosticReport.meta.profile", "path": "DiagnosticReport.meta.profile", "mustSupport": true }, { "id": "DiagnosticReport.basedOn", "path": "DiagnosticReport.basedOn", "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz", "http://hl7.org/fhir/StructureDefinition/CarePlan" ] } ], "mustSupport": true }, { "id": "DiagnosticReport.code", "path": "DiagnosticReport.code", "short": "Pathology report code", "mustSupport": true }, { "id": "DiagnosticReport.code.coding", "path": "DiagnosticReport.code.coding", "slicing": { "discriminator": [ { "type": "pattern", "path": "$this" } ], "rules": "open" }, "min": 1, "mustSupport": true }, { "id": "DiagnosticReport.code.coding:pathology-report", "path": "DiagnosticReport.code.coding", "sliceName": "pathology-report", "min": 1, "max": "1", "patternCoding": { "code": "60568-3", "system": "http://loinc.org" }, "mustSupport": true }, { "id": "DiagnosticReport.code.coding:pathology-report.system", "path": "DiagnosticReport.code.coding.system", "min": 1, "mustSupport": true }, { "id": "DiagnosticReport.code.coding:pathology-report.code", "path": "DiagnosticReport.code.coding.code", "min": 1, "mustSupport": true }, { "id": "DiagnosticReport.subject", "path": "DiagnosticReport.subject", "min": 1, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] } ], "mustSupport": true }, { "id": "DiagnosticReport.encounter", "path": "DiagnosticReport.encounter", "mustSupport": true }, { "id": "DiagnosticReport.specimen", "path": "DiagnosticReport.specimen", "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen", "http://hl7.org/fhir/StructureDefinition/Specimen" ] } ], "mustSupport": true }, { "id": "DiagnosticReport.conclusion", "path": "DiagnosticReport.conclusion", "min": 1, "mustSupport": true, "mapping": [ { "identity": "oBDS", "map": "6.11", "comment": "Befund" } ] } ] } }
Mapping Datensatz zu FHIR
Datensatz | Erklaerung | FHIR |
---|---|---|
Befund | Vollständiger Befundbericht des Pathologen. | DiagnosticReport.code.coding.where(system='http://loinc.org' and code='60568-3').select(%resource.conclusion) |
Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) zu FHIR
oBDS | Definition | FHIR |
---|---|---|
6.11 | Befund | DiagnosticReport.conclusion |
Suchparameter
Folgende Suchparameter sind für das Modul Onkologie relevant, auch in Kombination:
Der Suchparameter _id
MUSS unterstützt werden:
Beispiele:
GET [base]/Condition?_id=1234
Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:
Beispiele:
GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund
Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Beispiele
{ "resourceType": "DiagnosticReport", "id": "mii-exa-onko-befund-1", "meta": { "profile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund" ] }, "code": { "coding": [ { "code": "60568-3", "system": "http://loinc.org" } ] }, "status": "final", "subject": { "reference": "Patient/example" }, "basedOn": [ { "reference": "CarePlan/example-tumorboard-1" } ], "specimen": [ { "reference": "Specimen/example-specimen-2" } ], "conclusion": "Mäßig differenziertes invasiv duktales Karzinom (8500/3), Grading G2 an der rechten Mamma, ... " }