MII IG Kerndatensatz-Modul Bildgebung
2027.0.0-ballot.1 - Germany

This page is part of the MII Implementation Guide Bildgebung (v2027.0.0-ballot.1: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Ressourcenprofil: MII PR Bildgebung Radiologischer Befund

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund Version: 2027.0.0-ballot.1
Active Stand: 2026-09-15 Maschinenlesbarer Name: MII_PR_Bildgebung_Radiologischer_Befund

Darstellung des Befundberichts

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

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

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

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

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

Die Zuordnung der Datensatz-Elemente zu diesem Profil ist im Logischen Modell Bildgebung dokumentiert.

Beispiele

Beispiel einer DiagnosticReport-Ressource

​DiagnosticReport-mii-exa-bildgebung-radiologischer-Befund

Usages:

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... source SΣ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(MII PR Bildgebung Anforderung Bildgebung | CarePlan) Anforderung
... status ?!SΣ 1..1 code Status
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..* CodeableConcept Kategorie
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:loinc SΣ 0..1 Coding LOINC Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
..... coding:diagnostic-service-sections SΣ 0..1 Coding Diagnostic Service Section Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 1..1 string Representation defined by the system
Fixed Value: Radiology
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
..... coding:sct SΣ 1..1 Coding SNOMED CT Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 1..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:loinc SΣ 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Patient) Person
... encounter SΣ 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] SΣ 0..1 Erstellungsdatum
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for report
... issued SΣ 0..1 instant Erstellungszeitpunkt
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:icd10-gm SΣ 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base preferred LOINC Diagnostic Report Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport 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-4 error DiagnosticReport 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von DiagnosticReport

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id S 0..1 id Logical id of this artifact
... meta S 0..1 Meta Metadata about the resource
.... source S 0..1 uri Identifies where the resource comes from
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... status S 1..1 code Status
... category S 1..* CodeableConcept Kategorie
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:loinc S 0..1 Coding LOINC Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
...... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
..... coding:diagnostic-service-sections S 0..1 Coding Diagnostic Service Section Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
...... display 1..1 string Representation defined by the system
Fixed Value: Radiology
..... coding:sct S 1..1 Coding SNOMED CT Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 1..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
... code S 1..1 CodeableConcept Code
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:sct S 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
..... coding:loinc S 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
... subject S 1..1 Reference(Patient) Person
... encounter S 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] S 0..1 dateTime, Period Erstellungsdatum
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod S 0..1 Period Clinically relevant time/time-period for report
... issued S 0..1 instant Erstellungszeitpunkt
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:icd10-gm S 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
..... coding:sct S 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source SΣ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(MII PR Bildgebung Anforderung Bildgebung | CarePlan) Anforderung
... status ?!SΣ 1..1 code Status
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..* CodeableConcept Kategorie
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 0..1 Coding LOINC Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:diagnostic-service-sections SΣ 0..1 Coding Diagnostic Service Section Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Radiology
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 1..1 Coding SNOMED CT Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Person
... encounter SΣ 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] SΣ 0..1 Erstellungsdatum
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for report
... issued SΣ 0..1 instant Erstellungszeitpunkt
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-gm SΣ 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DiagnosticReport.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base preferred LOINC Diagnostic Report Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport 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-4 error DiagnosticReport 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von DiagnosticReport

Summary

Mandatory: 8 elements(5 nested mandatory elements)
Must-Support: 36 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DiagnosticReport.category.coding
  • The element 1 is sliced based on the value of DiagnosticReport.code.coding
  • The element 1 is sliced based on the value of DiagnosticReport.effective[x]
  • The element 1 is sliced based on the value of DiagnosticReport.conclusionCode.coding

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... source SΣ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(MII PR Bildgebung Anforderung Bildgebung | CarePlan) Anforderung
... status ?!SΣ 1..1 code Status
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..* CodeableConcept Kategorie
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:loinc SΣ 0..1 Coding LOINC Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
..... coding:diagnostic-service-sections SΣ 0..1 Coding Diagnostic Service Section Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 1..1 string Representation defined by the system
Fixed Value: Radiology
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
..... coding:sct SΣ 1..1 Coding SNOMED CT Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 1..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:loinc SΣ 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code SΣ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Patient) Person
... encounter SΣ 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] SΣ 0..1 Erstellungsdatum
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for report
... issued SΣ 0..1 instant Erstellungszeitpunkt
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system SΣ 1..1 uri Identity of the terminology system
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:icd10-gm SΣ 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... code SΣ 1..1 code Symbol in syntax defined by the system
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... version 0..1 string Version of the system - if relevant
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base preferred LOINC Diagnostic Report Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport 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-4 error DiagnosticReport 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential-Ansicht

Diese Struktur ist abgeleitet von DiagnosticReport

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id S 0..1 id Logical id of this artifact
... meta S 0..1 Meta Metadata about the resource
.... source S 0..1 uri Identifies where the resource comes from
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... status S 1..1 code Status
... category S 1..* CodeableConcept Kategorie
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:loinc S 0..1 Coding LOINC Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
...... display 1..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
..... coding:diagnostic-service-sections S 0..1 Coding Diagnostic Service Section Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
...... display 1..1 string Representation defined by the system
Fixed Value: Radiology
..... coding:sct S 1..1 Coding SNOMED CT Code
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version 1..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
...... display 1..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
... code S 1..1 CodeableConcept Code
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:sct S 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
..... coding:loinc S 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
... subject S 1..1 Reference(Patient) Person
... encounter S 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] S 0..1 dateTime, Period Erstellungsdatum
Slice: Unordered, Open by type:$this
.... effective[x]:effectiveDateTime S 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod S 0..1 Period Clinically relevant time/time-period for report
... issued S 0..1 instant Erstellungszeitpunkt
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
.... Slices for coding S 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system S 1..1 uri Identity of the terminology system
...... code S 1..1 code Symbol in syntax defined by the system
..... coding:icd10-gm S 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
..... coding:sct S 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id SΣ 0..1 id Logical id of this artifact
... meta SΣ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source SΣ 0..1 uri Identifies where the resource comes from
.... profile SΣ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:supportingInfo S 0..* (Complex) Zusatzinformation
URL: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0 Extension
Slice: Unordered, Open by value:url
..... url 1..1 uri "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo"
..... value[x] 1..1 Reference(DiagnosticReport | Procedure) Value of extension
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(MII PR Bildgebung Anforderung Bildgebung | CarePlan) Anforderung
... status ?!SΣ 1..1 code Status
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
... category SΣ 1..* CodeableConcept Kategorie
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 0..1 Coding LOINC Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 18748-4
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Diagnostic imaging study
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:diagnostic-service-sections SΣ 0..1 Coding Diagnostic Service Section Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: RAD
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Radiology
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 1..1 Coding SNOMED CT Code

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ 0..1 string Version of the system - if relevant
Fixed Value: http://snomed.info/sct/900000000000207008/version/20260701
...... code SΣ 1..1 code Symbol in syntax defined by the system
Fixed Value: 4201000179104
...... display Σ 0..1 string Representation defined by the system
Fixed Value: Imaging report (record artifact)
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept Code
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung DiagnosticReport Code SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:loinc SΣ 0..1 Coding LOINC Code
Binding: MII VS Bildgebung DiagnosticReport Code Loinc (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Person
... encounter SΣ 0..1 Reference(Encounter) Versorgungssstellenkontakt
... Slices for effective[x] SΣ 0..1 Erstellungsdatum
Slice: Unordered, Closed by type:$this
.... effectiveDateTime dateTime
.... effectivePeriod Period
.... effective[x]:effectiveDateTime SΣ 0..1 dateTime Clinically relevant time/time-period for report
.... effective[x]:effectivePeriod SΣ 0..1 Period Clinically relevant time/time-period for report
... issued SΣ 0..1 instant Erstellungszeitpunkt
... performer Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(Observation) Ergebnis
... imagingStudy S 1..* Reference(MII PR Bildgebung Bildgebungsstudie) Bildgebungsstudie
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusion S 0..1 string Fazit
... conclusionCode S 0..* CodeableConcept Strukturiertes Fazit
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:icd10-gm SΣ 0..1 Coding ICD-10-GM Code
Binding: http://fhir.de/CodeSystem/bfarm/icd-10-gm (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://fhir.de/CodeSystem/bfarm/icd-10-gm
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:sct SΣ 0..1 Coding SNOMED CT Code
Binding: MII VS Bildgebung Findings SCT (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct|http://snomed.info/sct/900000000000207008/version/20260701
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... presentedForm S 0..* Attachment Anhang

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DiagnosticReport.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DiagnosticReport.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📍4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code Base preferred LOINC Diagnostic Report Codes 📍4.0.1 FHIR Std.
DiagnosticReport.code.​coding:sct Base required MII VS Bildgebung DiagnosticReport Code SCT 📦2027.0.0-ballot.1 This IG
DiagnosticReport.code.​coding:loinc Base required MII VS Bildgebung DiagnosticReport Code Loinc 📦2027.0.0-ballot.1 This IG
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.
DiagnosticReport.conclusionCode.​coding:icd10-gm Base required http://fhir.de/CodeSystem/bfarm/icd-10-gm Not State Unknown
DiagnosticReport.conclusionCode.​coding:sct Base required MII VS Bildgebung Findings SCT 📦2027.0.0-ballot.1 This IG

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DiagnosticReport 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-4 error DiagnosticReport 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-5 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Diese Struktur ist abgeleitet von DiagnosticReport

Summary

Mandatory: 8 elements(5 nested mandatory elements)
Must-Support: 36 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DiagnosticReport.category.coding
  • The element 1 is sliced based on the value of DiagnosticReport.code.coding
  • The element 1 is sliced based on the value of DiagnosticReport.effective[x]
  • The element 1 is sliced based on the value of DiagnosticReport.conclusionCode.coding

 

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