MII IG Modul Patho
2027.0.0-ballot - Germany

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

: Pathologie Befundbericht

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{
  "resourceType" : "Composition",
  "id" : "mii-exa-patho-composition",
  "meta" : {
    "profile" : [
      🔗 "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-composition|2027.0.0-ballot"
    ]
  },
  "language" : "de",
  "text" : {
    "status" : "extensions",
    "div" : "<div xml:lang=\"de\" lang=\"de\"><hr/><p><b>German</b></p><hr/><p class=\"res-header-id\"><b>Generated Narrative: Composition mii-exa-patho-composition</b></p><a name=\"mii-exa-patho-composition\"> </a><a name=\"hcmii-exa-patho-composition\"> </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-patho-composition.html\">MII PR Patho Composition</a> version: 2027.0.0-ballot</p></div><p><b>Composition Version Number</b>: 1</p><p><b>identifier</b>: Accession ID/E21.12345</p><p><b>status</b>: Final</p><p><b>type</b>: <span title=\"Codes:{http://ihe-d.de/CodeSystems/IHEXDStypeCode PATH}, {http://snomed.info/sct 371528001}\">Pathology report</span></p><p><b>encounter</b>: <a href=\"Encounter-mii-exa-patho-encounter-34555.html\">Encounter: status = finished; class = ambulatory (ActCode#AMB)</a></p><p><b>date</b>: 2021-06-08</p><p><b>author</b>: <a href=\"Practitioner-mii-exa-patho-practitioner-2346545.html\">Dr. Name</a></p><p><b>title</b>: Pathologie Befundbericht</p><h3>Attesters</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td style=\"display: none\">*</td><td>Legal</td><td><a href=\"Practitioner-mii-exa-patho-practitioner-765879.html\">Practitioner Frank Färber </a></td></tr></table><p><b>custodian</b>: <a href=\"Organization-mii-exa-patho-organization-123456.html\">Organization Klinikum Musterstadt</a></p><h3>Events</h3><table class=\"grid\"><tr><td style=\"display: none\">-</td><td><b>Period</b></td></tr><tr><td style=\"display: none\">*</td><td>2021-06-05 --&gt; 2021-06-08</td></tr></table></div>"
  },
  "extension" : [
    {
      "url" : "http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber",
      "valueString" : "1"
    }
  ],
  "identifier" : {
    "type" : {
      "coding" : [
        {
          "system" : "http://terminology.hl7.org/CodeSystem/v2-0203",
          "code" : "ACSN",
          "display" : "Accession ID"
        }
      ]
    },
    "system" : "https://pathologie.klinikum-karlsruhe.de/fhir/fn/befundbericht",
    "value" : "E21.12345"
  },
  "status" : "final",
  "type" : {
    "coding" : [
      {
        "system" : "http://ihe-d.de/CodeSystems/IHEXDStypeCode",
        "code" : "PATH"
      },
      {
        "system" : "http://snomed.info/sct",
        "code" : "371528001",
        "display" : "Pathology report"
      }
    ]
  },
  "subject" : {
    🔗 "reference" : "Patient/mii-exa-patho-patient-34545"
  },
  "encounter" : {
    🔗 "reference" : "Encounter/mii-exa-patho-encounter-34555"
  },
  "date" : "2021-06-08",
  "author" : [
    {
      🔗 "reference" : "Practitioner/mii-exa-patho-practitioner-2346545",
      "display" : "Dr. Name"
    }
  ],
  "title" : "Pathologie Befundbericht",
  "attester" : [
    {
      "mode" : "legal",
      "party" : {
        🔗 "reference" : "Practitioner/mii-exa-patho-practitioner-765879"
      }
    }
  ],
  "custodian" : {
    🔗 "reference" : "Organization/mii-exa-patho-organization-123456"
  },
  "event" : [
    {
      "period" : {
        "start" : "2021-06-05",
        "end" : "2021-06-08"
      }
    }
  ],
  "section" : [
    {
      "title" : "Pathology Diagnostic Report",
      "code" : {
        "coding" : [
          {
            "system" : "http://loinc.org",
            "code" : "60567-5",
            "display" : "Comprehensive pathology report panel"
          }
        ]
      },
      "text" : {
        "status" : "additional",
        "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Gesamter Textkörper des Befundberichts, z.B. beginnend mit Makroskopie:</b></p><div id=\"macro-a-title\"><b>Makroskopie A</b></div><table><tr id=\"macro-a-biosy-site\"><td id=\"macro-a-biosy-site-key\">Entnahmeort lt. klin. Angabe</td><td id=\"macro-a-biosy-site-value\">Prostataseitenlappen rechts, lateral</td></tr><tr id=\"macro-a-tissue-length\"><td id=\"macro-a-tissue-length-key\">Stanzzylinderlänge</td><td id=\"macro-a-tissue-length-value\">1,2 cm</td></tr></table></div>"
      },
      "entry" : [
        {
          🔗 "reference" : "DiagnosticReport/mii-exa-patho-report"
        }
      ]
    }
  ]
}