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

Resource Profile: MII PR Bildgebung Radiologischer Befund

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

The profile describes a diagnostic report for a radiological image.

The DiagnosticReport for imaging procedures addresses the documentation of radiological reporting results. Different systems (RIS reporting modules, AI integrations, dedicated systems for structured reporting) deliver information at different levels of detail. This profile addresses these different levels of detail and offers modular stages that build on one another. Each stage adds further concepts and thus enables new fields of application, from routine care up to scientific analyses.

Stage 1 - Free text in structured form
At the most basic level, the DiagnosticReport resource enables the inclusion of radiological findings as free text in a structured form. This allows a simple yet effective representation of diagnostic information. The free-text description offers the possibility to transmit essential findings without complex data exchange.

Stage 2 - Linking of Observation resources
At the next stage, DiagnosticReport resources are linked with Observation resources. This allows a more detailed capture and representation of specific findings or measured values. Since these resources are machine-readable and coded, it is possible to search these contents, use them for analyses, or drive workflows.

Stage 3 - Reference to anatomical structures
Linking with BodyStructure resources is an enhancement that makes it possible to assign observations precisely to anatomical structures. This reference is particularly important for longitudinal patient care, as it enables tracking of and reference to specific lesions or anomalies in follow-up examinations or in other clinical contexts, such as pathology. Importantly, the BodyStructure resource is not part of the DiagnosticReport. Observations must therefore reference this resource in a versioned manner.

Stage 4 - Introduction of reading procedures
The integration of Procedure resources offers a further level of detail by describing the context / conditions under which the observations were made. This allows deeper insight into the circumstances of the reading by clearly defining according to which criteria and prerequisites specific information and measured values were captured. Linking with Procedure resources thus extends the diagnostic report with important contextual information that can be decisive for the interpretation of the findings.

The mapping of the dataset elements to this profile is documented in the Logical Model Bildgebung.

Examples

Example of a DiagnosticReport resource:

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

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and their representations.

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()

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()

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

Key Elements View

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 View

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 ViewView

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()

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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