MII IG Modul Patho - Local Development build (v2027.0.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Profiles

All elements of the core data set, adapted to the details and requirements of the use cases of the Medical Informatics Initiative, are described as FHIR StructureDefinitions. The necessity of each adaptation is explained in textual form below the respective profile.

The work on the core data set specifications is based, wherever possible, on international standards and terminologies — in particular the Anatomic Pathology Structured Report (APSR) and the International Patient Summary (IPS). The adaptation to the conditions of the German healthcare system is achieved by using the German base profiles of HL7 Deutschland.

Overview

Profile	Resource	Purpose
MII PR Patho Report	DiagnosticReport	The complete pathology report, without document properties
MII PR Patho Composition	Composition	Document header and structure of the report
MII PR Patho Bundle	Bundle	Signable document bundle
MII PR Patho Service Request	ServiceRequest	Examination request of the sender
MII PR Patho Specimen	Specimen	Specimen at every processing level (part, block, section)
MII PR Patho Base Observation	Observation (abstract)	Common basis of all observations in this module
MII PR Patho Section Grouper	Observation (abstract)	Basis of the observation report sections
MII PR Patho Intraoperative Grouper	Observation	Section intraoperative assessment
MII PR Patho Macroscopic Grouper	Observation	Section macroscopic assessment
MII PR Patho Microscopic Grouper	Observation	Section microscopic assessment
MII PR Patho Additional Specified Grouper	Observation	Section additional specified observations
MII PR Patho Diagnostic Conclusion Grouper	Observation	Section diagnostic conclusion
MII PR Patho Finding	Observation	Semantically annotated individual observation
MII PR Patho Attached Image	Media	Image embedded in the report
MII PR Patho Active Problems List	List	Clinical question of the sender
MII PR Patho History Of Present Illness	List	Medical history provided by the sender
MII PR Patho Problem List Item	Condition	Individual entry of the two lists
MII LM Patho Logical Model	Logical Model	Information model of the module

The complete, automatically generated list of all artifacts, including terminologies and examples, can be found under Overview.

Mandatory and must-support elements

For mandatory elements or elements marked as must-support, the corresponding rules of the International Patient Summary apply, which also apply to this implementation guide.

Requirement documentation

Requirements in this specification are marked by the following keywords written in capital letters, based on RFC-2119:

German	English
MUSS / MÜSSEN	MUST / SHALL
DARF NICHT / DÜRFEN NICHT	MUST NOT / SHALL NOT
VERPFLICHTEND	REQUIRED
SOLLTE / SOLLTEN	SHOULD
SOLLTE NICHT / SOLLTEN NICHT	SHOULD NOT
EMPFOHLEN	RECOMMENDED
KANN / OPTIONAL	MAY

Pathology observations

All observations in the module Pathology Report have the abstract profile MII PR Patho Base Observation as their common basis.

Overall view of all profiles and references