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

MII IG Kerndatensatz-Modul Bildgebung - Downloaded Version 2027.0.0-ballot.1 See the Directory of published versions

: MII Example Bildgebung Diagnostic Report

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<DiagnosticReport xmlns="http://hl7.org/fhir">
  <id value="mii-exa-bildgebung-radiologischer-befund"/>
  <meta>
    <profile
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund"/>
  </meta>
  <language value="en"/>
  <text>
    <status value="generated"/>
    <div xml:lang="en" lang="en"><hr/><p><b>English</b></p><hr/><p class="res-header-id"><b>Generated Narrative: DiagnosticReport mii-exa-bildgebung-radiologischer-befund</b></p><a name="mii-exa-bildgebung-radiologischer-befund"> </a><a name="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>
  </text>
  <basedOn>🔗 
    <reference
               value="ServiceRequest/mii-exa-bildgebung-anforderung-bildgebung"/>
  </basedOn>
  <status value="final"/>
  <category>
    <coding>
      <system value="http://snomed.info/sct"/>
      <version
               value="http://snomed.info/sct/900000000000207008/version/20260701"/>
      <code value="4201000179104"/>
      <display value="Imaging report (record artifact)"/>
    </coding>
  </category>
  <code>
    <coding>
      <system value="http://snomed.info/sct"/>
      <version
               value="http://snomed.info/sct/900000000000207008/version/20260701"/>
      <code value="4231000179109"/>
      <display value="Mammography report"/>
    </coding>
  </code>
  <subject>🔗 
    <reference value="Patient/mii-exa-bildgebung-radiologischer-patient"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/mii-exa-bildgebung-radiologischer-fall"/>
  </encounter>
  <effectiveDateTime value="2024-07-19T12:03:30+02:00"/>
  <issued value="2024-07-19T12:03:30+02:00"/>
  <result>🔗 
    <reference
               value="Observation/mii-exa-bildgebung-radiologische-beobachtung"/>
  </result>
  <imagingStudy>🔗 
    <reference value="ImagingStudy/mii-exa-bildgebung-bildgebungsstudie-ct"/>
  </imagingStudy>
  <conclusion
              value="There are suspicious microcalcifications in the upper outer quadrant in the left breast"/>
  <conclusionCode>
    <coding>
      <system value="http://snomed.info/sct"/>
      <version
               value="http://snomed.info/sct/900000000000207008/version/20260701"/>
      <code value="44771000"/>
      <display value="Microcalcifications of the breast (disorder)"/>
    </coding>
  </conclusionCode>
</DiagnosticReport>