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

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: MII Example Bildgebung Diagnostic Report

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{
  "resourceType" : "DiagnosticReport",
  "id" : "mii-exa-bildgebung-radiologischer-befund",
  "meta" : {
    "profile" : [
      🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund"
    ]
  },
  "language" : "de",
  "text" : {
    "status" : "generated",
    "div" : "<div xml:lang=\"de\" lang=\"de\"><hr/><p><b>German</b></p><hr/><p class=\"res-header-id\"><b>Generated Narrative: DiagnosticReport mii-exa-bildgebung-radiologischer-befund</b></p><a name=\"de-mii-exa-bildgebung-radiologischer-befund\"> </a><a name=\"de-hcmii-exa-bildgebung-radiologischer-befund\"> </a><div style=\"display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border: 1px solid #8da1b4; border-radius: 5px; line-height: 60%\"><p style=\"margin-bottom: 0px\"/><p style=\"margin-bottom: 0px\">Profile: <a href=\"StructureDefinition-mii-pr-bildgebung-radiologischer-befund.html\">MII PR Bildgebung Radiologischer Befund</a></p></div><h2><span title=\"Codes:{http://snomed.info/sct 4231000179109}\">Mammography report</span> (<span title=\"Codes:{http://snomed.info/sct 4201000179104}\">Imaging report (record artifact)</span>) </h2><table class=\"grid\"><tr><td>Subject</td><td>Erika Beispielpatientin  Female, DoB: 1970-01-01</td></tr><tr><td>Relevant Time</td><td>2024-07-19 12:03:30+0200</td></tr><tr><td>Reported</td><td>2024-07-19 12:03:30+0200</td></tr></table><p><b>Report Details</b></p><table class=\"grid\"><tr><td><b>Code</b></td><td><b>Value</b></td><td><b>Flags</b></td></tr><tr><td><a href=\"Observation-mii-exa-bildgebung-radiologische-beobachtung.html\"><span title=\"Codes:{http://loinc.org 32422-8}\">Physical findings of Breast</span></a> (<span title=\"Codes:{http://snomed.info/sct 76752008}\">Breast structure (body structure)</span>)</td><td>microcalcifications in the upper outer quadrant in the left breast</td><td>Final</td></tr></table><p>There are suspicious microcalcifications in the upper outer quadrant in the left breast</p><p><b>Coded Conclusions:</b></p><ul><li><span title=\"Codes:{http://snomed.info/sct 44771000}\">Microcalcifications of the breast (disorder)</span></li></ul></div>"
  },
  "basedOn" : [
    {
      🔗 "reference" : "ServiceRequest/mii-exa-bildgebung-anforderung-bildgebung"
    }
  ],
  "status" : "final",
  "category" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "version" : "http://snomed.info/sct/900000000000207008/version/20260701",
          "code" : "4201000179104",
          "display" : "Imaging report (record artifact)"
        }
      ]
    }
  ],
  "code" : {
    "coding" : [
      {
        "system" : "http://snomed.info/sct",
        "version" : "http://snomed.info/sct/900000000000207008/version/20260701",
        "code" : "4231000179109",
        "display" : "Mammography report"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/mii-exa-bildgebung-radiologischer-patient"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/mii-exa-bildgebung-radiologischer-fall"
  },
  "effectiveDateTime" : "2024-07-19T12:03:30+02:00",
  "issued" : "2024-07-19T12:03:30+02:00",
  "result" : [
    {
      🔗 "reference" : "Observation/mii-exa-bildgebung-radiologische-beobachtung"
    }
  ],
  "imagingStudy" : [
    {
      🔗 "reference" : "ImagingStudy/mii-exa-bildgebung-bildgebungsstudie-ct"
    }
  ],
  "conclusion" : "There are suspicious microcalcifications in the upper outer quadrant in the left breast",
  "conclusionCode" : [
    {
      "coding" : [
        {
          "system" : "http://snomed.info/sct",
          "version" : "http://snomed.info/sct/900000000000207008/version/20260701",
          "code" : "44771000",
          "display" : "Microcalcifications of the breast (disorder)"
        }
      ]
    }
  ]
}