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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<Composition xmlns="http://hl7.org/fhir">
  <id value="mii-exa-patho-composition"/>
  <meta>
    <profile
             value="https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-composition|2027.0.0-ballot"/>
  </meta>
  <language value="de"/>
  <text>
    <status value="extensions"/>
    <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>
  </text>
  <extension
             url="http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber">
    <valueString value="1"/>
  </extension>
  <identifier>
    <type>
      <coding>
        <system value="http://terminology.hl7.org/CodeSystem/v2-0203"/>
        <code value="ACSN"/>
        <display value="Accession ID"/>
      </coding>
    </type>
    <system
            value="https://pathologie.klinikum-karlsruhe.de/fhir/fn/befundbericht"/>
    <value value="E21.12345"/>
  </identifier>
  <status value="final"/>
  <type>
    <coding>
      <system value="http://ihe-d.de/CodeSystems/IHEXDStypeCode"/>
      <code value="PATH"/>
    </coding>
    <coding>
      <system value="http://snomed.info/sct"/>
      <code value="371528001"/>
      <display value="Pathology report"/>
    </coding>
  </type>
  <subject>🔗 
    <reference value="Patient/mii-exa-patho-patient-34545"/>
  </subject>
  <encounter>🔗 
    <reference value="Encounter/mii-exa-patho-encounter-34555"/>
  </encounter>
  <date value="2021-06-08"/>
  <author>🔗 
    <reference value="Practitioner/mii-exa-patho-practitioner-2346545"/>
    <display value="Dr. Name"/>
  </author>
  <title value="Pathologie Befundbericht"/>
  <attester>
    <mode value="legal"/>
    <party>🔗 
      <reference value="Practitioner/mii-exa-patho-practitioner-765879"/>
    </party>
  </attester>
  <custodian>🔗 
    <reference value="Organization/mii-exa-patho-organization-123456"/>
  </custodian>
  <event>
    <period>
      <start value="2021-06-05"/>
      <end value="2021-06-08"/>
    </period>
  </event>
  <section>
    <title value="Pathology Diagnostic Report"/>
    <code>
      <coding>
        <system value="http://loinc.org"/>
        <code value="60567-5"/>
        <display value="Comprehensive pathology report panel"/>
      </coding>
    </code>
    <text>
      <status value="additional"/>
      <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>
    </text>
    <entry>🔗 
      <reference value="DiagnosticReport/mii-exa-patho-report"/>
    </entry>
  </section>
</Composition>