MII IG Onkologie DE v2025
Histologiebefund: DiagnosticReport
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 | active | 2025.1.0 | https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund | http://hl7.org/fhir/StructureDefinition/DiagnosticReport |
Inhalt
| MII_PR_Onko_Befund (DiagnosticReport) | C | DiagnosticReport | |
| id | Σ | 0..1 | string |
| meta | Σ | 0..1 | Meta |
| id | 0..1 | string | |
| extension | C | 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 | C | 0..* | Extension |
| modifierExtension | ?! C | 0..* | Extension |
| identifier | Σ | 0..* | Identifier |
| basedOn | S C | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) |
| tumorkonferenz | S C | 0..1 | Reference(MII_PR_Onko_Tumorkonferenz) |
| status | Σ ?! | 1..1 | codeBinding |
| category | Σ | 0..* | CodeableConcept |
| code | S Σ | 1..1 | CodeableConceptBinding |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| coding | S Σ | 1..* | Coding |
| pathology-report | S Σ | 1..1 | CodingPattern |
| id | 0..1 | string | |
| extension | C | 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 C | 1..1 | Reference(Patient) |
| encounter | S Σ C | 0..1 | Reference(Encounter) |
| effective[x] | Σ | 0..1 | |
| effectiveDateTime | dateTime | ||
| effectivePeriod | Period | ||
| issued | Σ | 0..1 | instant |
| performer | Σ C | 0..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) |
| resultsInterpreter | Σ C | 0..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) |
| specimen | S C | 0..* | Reference(Specimen | MII_PR_Onko_Specimen) |
| result | C | 0..* | Reference(Observation) |
| imagingStudy | C | 0..* | Reference(ImagingStudy) |
| media | Σ | 0..* | BackboneElement |
| id | 0..1 | string | |
| extension | C | 0..* | Extension |
| modifierExtension | Σ ?! C | 0..* | Extension |
| comment | 0..1 | string | |
| link | Σ C | 1..1 | Reference(Media) |
| conclusion | S | 1..1 | string |
| conclusionCode | 0..* | CodeableConcept | |
| presentedForm | C | 0..* | Attachment |
Histologie: Befund. Vollständiger Befundbericht des Pathologen. |
| Feldname | Kurzbeschreibung |
|---|---|
| DiagnosticReport.meta.profile | |
| DiagnosticReport.basedOn | |
| DiagnosticReport.basedOn:tumorkonferenz | |
| 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 | Befund als Freitext |
<url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund" />
</telecom>
</contact>
</mapping>
<short value="A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports" />
<definition value="The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports." />
<comment value="This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing." />
</base>
<human value="If the resource is contained in another resource, it SHALL NOT contain nested Resources" />
</constraint>
<human value="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" />
<expression value="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()" />
<xpath value="not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))" />
</constraint>
<human value="If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated" />
<xpath value="not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))" />
</constraint>
<human value="If a resource is contained in another resource, it SHALL NOT have a security label" />
</constraint>
</extension>
<extension url="http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation">
<valueMarkdown value="When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." />
</extension>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes." />
<comment value="The only time that a resource does not have an id is when it is being submitted to the server using a create operation." />
</base>
</extension>
</type>
</element>
<definition value="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." />
</base>
</type>
</constraint>
</element>
<definition value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces." />
</base>
</extension>
</type>
</mapping>
</element>
</discriminator>
</slicing>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</constraint>
</mapping>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</element>
<comment value="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](http.html#read) interaction." />
</base>
</type>
</constraint>
</element>
<definition value="A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](provenance.html#) 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." />
<comment value="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. \n\nThis 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." />
</base>
</type>
</constraint>
</element>
<definition value="A list of profiles (references to [StructureDefinition](structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](structuredefinition-definitions.html#StructureDefinition.url)." />
<comment value="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." />
</base>
</type>
</constraint>
</element>
<definition value="Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure." />
<comment value="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." />
</base>
</type>
</constraint>
</extension>
</extension>
<description value="Security Labels from the Healthcare Privacy and Security Classification System." />
</binding>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</extension>
<description value="Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones"." />
</binding>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
<isModifierReason value="This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation" />
</element>
<comment value="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)." />
</base>
</type>
</constraint>
</extension>
</extension>
</extension>
</binding>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</mapping>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</mapping>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</constraint>
</mapping>
</element>
<definition value="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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself)." />
<comment value="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." />
<requirements value="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](extensibility.html#modifierExtension)." />
</base>
</type>
</constraint>
</constraint>
<isModifierReason value="Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them" />
</mapping>
</element>
<comment value="Usually assigned by the Information System of the diagnostic service provider (filler id)." />
<requirements value="Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context." />
</base>
</type>
</constraint>
</mapping>
</mapping>
<map value="OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4" />
</mapping>
</mapping>
</element>
</discriminator>
</slicing>
<comment value="Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports." />
<requirements value="This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<comment value="Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports." />
<requirements value="This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon." />
</base>
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz" />
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<requirements value="Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports." />
</base>
</type>
</constraint>
<isModifierReason value="This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid" />
</extension>
</binding>
</mapping>
</mapping>
</mapping>
<map value="statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"" />
</mapping>
</element>
<definition value="A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes." />
<comment value="Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code." />
</base>
</type>
</constraint>
</extension>
</binding>
</mapping>
</mapping>
<map value="inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code" />
</mapping>
</element>
</base>
</type>
</constraint>
</extension>
</binding>
</mapping>
</mapping>
<map value="OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)" />
</mapping>
</mapping>
</element>
<definition value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces." />
</base>
</extension>
</type>
</mapping>
</element>
</discriminator>
</slicing>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</constraint>
</mapping>
</element>
</discriminator>
</slicing>
<comment value="Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true." />
<requirements value="Allows for alternative encodings within a code system, and translations to other code systems." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<comment value="Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true." />
<requirements value="Allows for alternative encodings within a code system, and translations to other code systems." />
</base>
</type>
</patternCoding>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<definition value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces." />
</base>
</extension>
</type>
</mapping>
</element>
</discriminator>
</slicing>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</constraint>
</mapping>
</element>
<definition value="The identification of the code system that defines the meaning of the symbol in the code." />
<comment value="The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged." />
<comment value="Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<definition value="A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination)." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
</extension>
<definition value="A representation of the meaning of the code in the system, following the rules of the system." />
<requirements value="Need to be able to carry a human-readable meaning of the code for readers that do not know the system." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<definition value="Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays)." />
<comment value="Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely." />
<requirements value="This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing." />
</base>
</type>
</constraint>
</mapping>
</mapping>
<map value="fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]" />
</mapping>
</element>
</extension>
<definition value="A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user." />
<requirements value="The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about." />
<comment value="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)." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself." />
<comment value="If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic." />
</base>
</type>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified." />
<comment value="May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</element>
<comment value="This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report." />
<requirements value="Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<definition value="The practitioner or organization that is responsible for the report's conclusions and interpretations." />
<requirements value="Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</mapping>
</mapping>
</element>
<comment value="If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group." />
<requirements value="Need to be able to report information about the collected specimens on which the report is based." />
</base>
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen" />
</type>
</constraint>
</mapping>
</mapping>
</element>
<requirements value="Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</element>
<definition value="One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images." />
<comment value="ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided." />
</base>
</type>
</constraint>
</mapping>
</element>
<definition value="A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest)." />
<requirements value="Many diagnostic services include images in the report as part of their service." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</element>
<definition value="Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces." />
</base>
</extension>
</type>
</mapping>
</element>
<definition value="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." />
<comment value="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." />
</base>
</type>
</constraint>
</constraint>
</mapping>
</element>
<definition value="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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself)." />
<comment value="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." />
<requirements value="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](extensibility.html#modifierExtension)." />
</base>
</type>
</constraint>
</constraint>
<isModifierReason value="Modifier extensions are expected to modify the meaning or interpretation of the element that contains them" />
</mapping>
</element>
<definition value="A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features." />
<comment value="The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion." />
<requirements value="The provider of the report should make a comment about each image included in the report." />
</base>
</type>
</constraint>
<map value=".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value" />
</mapping>
</element>
</base>
</type>
</constraint>
</mapping>
</element>
</extension>
</extension>
</extension>
</short>
</extension>
</extension>
</extension>
</definition>
<requirements value="Need to be able to provide a conclusion that is not lost among the basic result data." />
</base>
</type>
</constraint>
</mapping>
<map value="inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)" />
</mapping>
</mapping>
</element>
<definition value="One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report." />
</base>
</type>
</constraint>
</extension>
</binding>
</mapping>
<map value="inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)" />
</mapping>
</element>
<definition value="Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent." />
<comment value=""application/pdf" is recommended as the most reliable and interoperable in this context." />
<requirements value="Gives laboratory the ability to provide its own fully formatted report for clinical fidelity." />
</base>
</type>
</constraint>
</mapping>
</mapping>
</element>
</snapshot>
</element>
</discriminator>
</slicing>
</element>
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz" />
</type>
</element>
</element>
</discriminator>
</slicing>
</element>
</patternCoding>
</element>
</element>
</element>
</type>
</element>
</element>
<targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen" />
</type>
</element>
</extension>
</extension>
</extension>
</short>
</extension>
</extension>
</extension>
</definition>
</mapping>
</element>
</differential>
</StructureDefinition>
{
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund",
],
],
{
"short": "A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports",
"definition": "The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.",
"comment": "This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.",
"Report",
"Test",
"Result",
"Results",
"Labs",
"Laboratory"
],
},
{
},
{
"human": "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",
"expression": "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()",
"xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
},
{
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
},
{
},
{
{
},
{
"valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
}
],
}
],
{
},
{
},
{
},
{
}
]
},
{
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
},
{
{
}
],
}
],
},
{
"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.",
},
],
{
}
],
},
{
"xmlAttr"
],
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
},
{
{
}
],
}
],
]
},
{
],
},
"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.",
"comment": "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.",
"extensions",
"user content"
],
},
],
{
},
{
}
],
]
},
{
"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.",
"comment": "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.",
},
],
{
}
],
},
{
"comment": "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](http.html#read) interaction.",
},
],
{
}
],
},
{
"definition": "A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](provenance.html#) 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.",
"comment": "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. \n\nThis 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.",
},
],
{
}
],
},
{
"definition": "A list of profiles (references to [StructureDefinition](structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](structuredefinition-definitions.html#StructureDefinition.url).",
"comment": "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.",
},
{
"http://hl7.org/fhir/StructureDefinition/StructureDefinition"
]
}
],
{
}
],
},
{
"definition": "Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.",
"comment": "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.",
},
],
{
}
],
{
},
{
}
],
}
},
{
"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.",
"comment": "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.",
},
],
{
}
],
{
}
],
"description": "Codes that represent various types of tags, commonly workflow-related; e.g. \"Needs review by Dr. Jones\".",
}
},
{
"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.",
"comment": "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.",
},
],
{
}
],
"isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
},
{
"comment": "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).",
},
],
{
}
],
{
},
{
},
{
}
],
}
},
{
"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.",
"comment": "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.",
"narrative",
"html",
"xhtml",
"display"
],
},
],
{
}
],
]
},
{
"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.",
"comment": "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.",
"inline resources",
"anonymous resources",
"contained resources"
],
},
],
]
},
{
"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.",
"comment": "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.",
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment": "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.",
"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](extensibility.html#modifierExtension).",
"extensions",
"user content"
],
},
],
{
},
{
}
],
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
]
},
{
"comment": "Usually assigned by the Information System of the diagnostic service provider (filler id).",
"requirements": "Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.",
"ReportID",
"Filler ID",
"Placer ID"
],
},
],
{
}
],
{
},
{
},
{
"map": "OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4"
},
{
}
]
},
{
},
"comment": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.",
"requirements": "This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.",
"Request"
],
},
{
"http://hl7.org/fhir/StructureDefinition/CarePlan",
"http://hl7.org/fhir/StructureDefinition/ImmunizationRecommendation",
"http://hl7.org/fhir/StructureDefinition/MedicationRequest",
"http://hl7.org/fhir/StructureDefinition/NutritionOrder",
"http://hl7.org/fhir/StructureDefinition/ServiceRequest"
]
}
],
{
}
],
{
},
{
},
{
}
]
},
{
"comment": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.",
"requirements": "This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.",
"Request"
],
},
{
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz"
]
}
],
{
}
],
{
},
{
},
{
}
]
},
{
"requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.",
},
],
{
}
],
"isModifierReason": "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
{
}
],
},
{
},
{
},
{
},
{
"map": "statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\""
}
]
},
{
"definition": "A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.",
"comment": "Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.",
"Department",
"Sub-department",
"Service",
"Discipline"
],
},
],
{
}
],
{
}
],
},
{
},
{
},
{
"map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code"
}
]
},
{
"Type"
],
},
],
{
}
],
{
}
],
},
{
},
{
},
{
"map": "OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)"
},
{
}
]
},
{
"xmlAttr"
],
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
},
{
{
}
],
}
],
]
},
{
],
},
"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.",
"comment": "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.",
"extensions",
"user content"
],
},
],
{
},
{
}
],
]
},
{
},
"comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.",
"requirements": "Allows for alternative encodings within a code system, and translations to other code systems.",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.",
"requirements": "Allows for alternative encodings within a code system, and translations to other code systems.",
},
],
},
{
}
],
{
},
{
},
{
}
]
},
{
"xmlAttr"
],
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
},
{
{
}
],
}
],
]
},
{
],
},
"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.",
"comment": "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.",
"extensions",
"user content"
],
},
],
{
},
{
}
],
]
},
{
"definition": "The identification of the code system that defines the meaning of the symbol in the code.",
"comment": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.",
"comment": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
{
}
],
"definition": "A representation of the meaning of the code in the system, following the rules of the system.",
"requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"definition": "Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).",
"comment": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.",
"requirements": "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
},
],
{
}
],
{
},
{
},
{
"map": "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]"
}
]
},
{
{
}
],
"definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.",
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"definition": "The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources.",
"Patient"
],
},
],
{
}
],
{
},
{
},
{
},
{
},
{
}
]
},
{
"definition": "The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.",
"comment": "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).",
"Context"
],
},
],
{
}
],
{
},
{
},
{
},
{
}
]
},
{
"definition": "The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself.",
"comment": "If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.",
"Observation time",
"Effective Time",
"Occurrence"
],
},
],
{
}
],
{
},
{
},
{
},
{
}
]
},
{
"definition": "The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.",
"comment": "May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report.",
"Date published",
"Date Issued",
"Date Verified"
],
},
],
{
}
],
{
},
{
},
{
}
]
},
{
"comment": "This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report.",
"requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.",
"Laboratory",
"Service",
"Practitioner",
"Department",
"Company",
"Authorized by",
"Director"
],
},
{
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization",
"http://hl7.org/fhir/StructureDefinition/CareTeam"
]
}
],
{
}
],
{
},
{
},
{
},
{
}
]
},
{
"definition": "The practitioner or organization that is responsible for the report's conclusions and interpretations.",
"requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.",
"Analyzed by",
"Reported by"
],
},
{
"http://hl7.org/fhir/StructureDefinition/Practitioner",
"http://hl7.org/fhir/StructureDefinition/PractitionerRole",
"http://hl7.org/fhir/StructureDefinition/Organization",
"http://hl7.org/fhir/StructureDefinition/CareTeam"
]
}
],
{
}
],
{
},
{
},
{
},
{
}
]
},
{
"comment": "If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group.",
"requirements": "Need to be able to report information about the collected specimens on which the report is based.",
},
{
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen",
"http://hl7.org/fhir/StructureDefinition/Specimen"
]
}
],
{
}
],
]
},
{
"requirements": "Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.",
"Data",
"Atomic Value",
"Result",
"Atomic result",
"Data",
"Test",
"Analyte",
"Battery",
"Organizer"
],
},
],
{
}
],
{
},
{
}
]
},
{
"definition": "One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.",
"comment": "ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.",
},
{
}
],
{
}
],
{
}
]
},
{
"definition": "A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).",
"DICOM",
"Slides",
"Scans"
],
},
],
{
}
],
{
},
{
}
]
},
{
"xmlAttr"
],
"definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
},
{
{
}
],
}
],
]
},
{
"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.",
"comment": "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.",
"extensions",
"user content"
],
},
],
{
},
{
}
],
]
},
{
"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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment": "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.",
"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](extensibility.html#modifierExtension).",
"extensions",
"user content",
"modifiers"
],
},
],
{
},
{
}
],
"isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
]
},
{
"definition": "A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.",
"comment": "The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.",
"requirements": "The provider of the report should make a comment about each image included in the report.",
},
],
{
}
],
{
"map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value"
}
]
},
{
},
],
{
}
],
]
},
{
{
],
}
]
},
{
{
},
{
}
],
}
]
},
"requirements": "Need to be able to provide a conclusion that is not lost among the basic result data.",
"Report"
],
},
],
{
}
],
{
},
{
"map": "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)"
},
{
}
]
},
{
"definition": "One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.",
},
],
{
}
],
{
}
],
},
{
},
{
"map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)"
}
]
},
{
"definition": "Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.",
"comment": "\"application/pdf\" is recommended as the most reliable and interoperable in this context.",
"requirements": "Gives laboratory the ability to provide its own fully formatted report for clinical fidelity.",
},
],
{
}
],
]
}
]
},
{
},
{
},
},
{
{
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-tumorkonferenz"
]
}
],
},
{
},
{
},
},
{
},
},
{
},
{
},
{
],
},
{
},
{
{
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-specimen",
"http://hl7.org/fhir/StructureDefinition/Specimen"
]
}
],
},
{
{
],
}
]
},
{
{
},
{
}
],
}
]
},
]
}
]
}
}
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
_idMUSS unterstützt werden:Beispiele:
GET [base]/Condition?_id=1234Anwendungshinweise: 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-befundAnwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Beispiele
{
"https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund|2026.0.0"
]
},
],
},
},
],
"conclusion": "Mäßig differenziertes invasiv duktales Karzinom (8500/3), Grading G2 an der rechten Mamma, ..."
}