Logical Model for the graphical reprensentation of the respective Art-Decor Model

Der Identifikator eines Pathologiebefundberichts (z.B. E/20/12345.1) ist eineindeutig und wird meist aus der Eingangsnummer (Fall-Nummer) abgeleitet. Er sollte zusammengesetzt werden aus der Set-ID (z.B. E/20/12345), unter der alle Versionen eines Befundberichts erfasst werden, und der Versionsnummer (z.B. 1). Es ist allerdings auch möglich, einen UID (Unique identifier) oder GUID (Global Unique Identifier) zu verwenden, der keine Ableitung aus der Fallnummer darstellt. Üblicherweise wird die Fall-Nummer als Set-ID verwendet.

Status des Pathologiebefundberichts.

Zeitpunkt, an dem der Pathologiebefundbericht dokumentiert (verifiziert und freigegeben) wurde.

Auftrag zur Untersuchung einer Probe/eines Materials / einer Gruppe von Proben/einer Gruppe von Materialien.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Klinische Informationen zu einem Fall

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Fragestellung zum Fall

Anamnestische Angaben zum Fall

Überweisungsgrund

Diagnose nach gültiger ICD-10-GM

ID des Untersuchungsauftrags.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID einer Auftragsgruppe, bestehend aus mehreren Untersuchungsaufträgen

Auftrags-ID vom Auftraggeber vergeben

Auftrags-ID vom Auftragnehmer (Pathologie) vergeben, oft identisch mit Fall-Nr.

Status des pathologischen Untersuchungsauftrages

Beauftragte Untersuchung in kodierter Form

Arzt, der Proben eines Patienten zur pathologisch-anatomischen Untersuchung einsendet und der der Empfänger des Pathologiebefundberichtes ist.

Entnehmer einer Probe, der nicht identisch mit dem Einsender ist.

Organ oder Organteil oder eine Sammlung derselben, die als Einsendungspräparat zusammen mit dem Untersuchungsauftrag zur Bearbeitung und Begutachtung eingesandt werden.

Von einem Patienten gewonnenes Physisches Objekt oder Sammlung physischer Objekte, die als Einheit betrachtet werden, in der Pathologieeinrichtung eindeutig identifiziert sind und als Gegenstand einer oder mehrerer Prozeduren im Workflow gelten. Ein Einsendungspräparat (syn. Material, nur für Abrechnungszwecke verwendet, syn. Probe) resultiert aus einer Probengewinnungsprozedur und kann in mehreren Containern enthalten sein. Im Pathologielabor werden die Einsendungspräparate (Case), die aus mehreren Teilen (Parts) bestehen können, beginnend mit dem Zuschnitt, meist als Proben bezeichnet. Proben können einen oder mehrere Bearbeitungsschritte üblicherweise zu Blöcken und gefärbten Schnitten haben.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Eindeutiger Identifikator für die Probe (Einsendungspräparat). Formal oft identisch mit der Falleingangsnummer (Accession identifier).

Status der Probe hinsichtlich der Verfügbarkeit

Art der Probe

Zeitpunkt des Eingangs der Probe im Labor

Prozedur zur Probengewinnung an Patient:in

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Klinische Methode (Prozedur) der Probengewinnung (an Patient:in)

Lokalisation der Körperstelle, von der die Probe stammt.

Zeitpunkt der Ent- / Abnahme der Probe

Beobachtungen zu Eigenschaften des Einsendungspräparats / der Probe, z.B. Abmessungen, Randbeziehungen, Markierungen etc., die vom Einsender mitgeteilt werden.

Prozedur der Probenbearbeitung im Labor

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Kodierte Prozedur der Probenbearbeitung in der Pathologie

Referenz auf den Gegenstand der Bearbeitungsprozedur / auf die Elternprobe

Additive bei der Probenbearbeitung (Fixationsmittel, Einbettungs- und Eindeckungsmedien, Färbungen)

Textuelle Beschreibung der Probenbearbeitung.

Physikalisches Objekt, das Proben enthält oder trägt. Probenbehälter im weitesten Sinn: Einsendungsgefäß, Gewebskassette, Paraffinblock, Objektträger etc.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Identifikation des Containers, kann von Proben-ID verschieden sein

Typ des Containers

Additive im Container: Fixative im Einsendungsgefäß, Paraffin im Block, Einbettungsmedium auf dem Objektträger

Bericht über eine Beobachtung (Abschnitt eines Befundberichts), die zu einem Befund führt. Dieser Berichtsabschnitt kann generische kodierte anatomisch-pathologische Beobachtungen (Befunde) enthalten. Im Berichtsabschnitt Materialbearbeitung kann die gesamte Probengewinnung und -bearbeitung detailliert kodiert werden. Im Berichtsabschnitt Diagnostische Schlussfolgerung muss mindestens eine kodierte Beobachtung enthalten sein.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Die Intraoperative Begutachtungssektion (Schnellschnitt) enthält die intraoperative Diagnose für jedes übersandte Material, die Materialidentifikation und -beschreibung und Informationen über Proben, die für weitere Untersuchungen (z.B. Flowzytometrie, Molekularpathologie, Elektronenmikroskopie) abgeleitet wurden.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Text einer intraoperativen Beobachtung.

Semantisch annotierte atomare Einheit einer generischen pathologisch-anatomischen Beobachtung

Referenz zum eingebetteten Bild

Die Makroskopische Beurteilungssektion enthält die Beschreibung der Proben, des Zuschnitts und der makroskopische Befunde, verlinkt zu Makrobildern und Skizzen von Zuschnittssituationen. Sie sollte auch Informationen über Gewebsgele enthalten, die für zusätzliche Studien bereitgestellt oder an Biobanken gesandt wurden.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Makroskopischer Begutachtungstext

Semantisch annotierte atomare Einheit einer generischen pathologisch-anatomische Beobachtung

In eine Beobachtung eingebettetes Bild

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID des eingebetteten Bildes

Makro-Bild der Zuschnittsituation

Während des Zuschnitts des Materials werden auch Skizzen zur Schnittführung, zur Aufteilung von Gewebsstücken und zur Markierung angefertigt, um die resultierenden Blöcke und Schnitte topografisch dem Gewebe, aus dem sie entnommen wurden, zuordnen zu können.

Die Mikroskopische Begutachtungssektion enthält optional die histopathologischen Befunde des Falles. Sie sollte genutzt werden, um die Ergebnisse histochemischer und immunhistochemischer Färbungen und von bildgestützten molekularpathologischen Befunden aufzuzeichnen.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Mikroskopischer Beurteilungstext

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID des eingebetteten Bildes

Okularaufnahme oder WSI oder Screenshot von WSI

Region-of-interest

Ein für die jeweilige nicht-morphologische Beobachtung zutreffender LOINC-Code ist auszuwählen.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Text einer zusätzlichen spezifizierten Beobachtung

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID des eingebetteten Bildes

Ein der zusätzlichen, spezifizierten Beobachtung zugehöriges Dokument, z.B. ein molekularpathologischer Befundbericht, der mittels OMICS Ressourcen aus dem Untersuchungsmaterial der Pathologisch-anatomischen Begutachtung erstellt wurde.

Die Diagnostische Schlussfolgerungssektion enthält die Diagnose(n) an allen Materialien / Proben, die zu einem Fall eingesandt wurden. Diagnosen werden für jedes Material oder jede Gruppe von Materialien werden separat berichtet. Die Sektion schließt zusätzliche pathologische Befunde und Ergebnisse von unterstützenden Untersuchungen ein. Sie kann Diagramme, Bilder und virtuelle Schnitte enthalten. Für komplexe Beobachtungen, z.B. Tumorformeln, Score-Systeme, Gradings, etc. sollte auf entsprechende Profile aus anderen MII-Modulen zurückgegriffen werden. Wenn Cancer Checklists zur Befundberichtserstellung benutzt wurden, sollte dies ebenfalls in dieser Sektion eingeschlossen sein.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Text der diagnostischen Schlussfolgerung

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID des eingebetteten Bildes

Skizze

Makro-Bild

Mikro-Bild

Region-of-interest

Logical Model for the graphical reprensentation of the respective Art-Decor Model

Der Identifikator eines Pathologiebefundberichts (z.B. E/20/12345.1) ist eineindeutig und wird meist aus der Eingangsnummer (Fall-Nummer) abgeleitet. Er sollte zusammengesetzt werden aus der Set-ID (z.B. E/20/12345), unter der alle Versionen eines Befundberichts erfasst werden, und der Versionsnummer (z.B. 1). Es ist allerdings auch möglich, einen UID (Unique identifier) oder GUID (Global Unique Identifier) zu verwenden, der keine Ableitung aus der Fallnummer darstellt. Üblicherweise wird die Fall-Nummer als Set-ID verwendet.

Status des Pathologiebefundberichts.

Zeitpunkt, an dem der Pathologiebefundbericht dokumentiert (verifiziert und freigegeben) wurde.

Auftrag zur Untersuchung einer Probe/eines Materials / einer Gruppe von Proben/einer Gruppe von Materialien.

Klinische Informationen zu einem Fall

Fragestellung zum Fall

Anamnestische Angaben zum Fall

Überweisungsgrund

Diagnose nach gültiger ICD-10-GM

ID des Untersuchungsauftrags.

ID einer Auftragsgruppe, bestehend aus mehreren Untersuchungsaufträgen

Auftrags-ID vom Auftraggeber vergeben

Auftrags-ID vom Auftragnehmer (Pathologie) vergeben, oft identisch mit Fall-Nr.

Status des pathologischen Untersuchungsauftrages

Beauftragte Untersuchung in kodierter Form

Arzt, der Proben eines Patienten zur pathologisch-anatomischen Untersuchung einsendet und der der Empfänger des Pathologiebefundberichtes ist.

Entnehmer einer Probe, der nicht identisch mit dem Einsender ist.

Organ oder Organteil oder eine Sammlung derselben, die als Einsendungspräparat zusammen mit dem Untersuchungsauftrag zur Bearbeitung und Begutachtung eingesandt werden.

Von einem Patienten gewonnenes Physisches Objekt oder Sammlung physischer Objekte, die als Einheit betrachtet werden, in der Pathologieeinrichtung eindeutig identifiziert sind und als Gegenstand einer oder mehrerer Prozeduren im Workflow gelten. Ein Einsendungspräparat (syn. Material, nur für Abrechnungszwecke verwendet, syn. Probe) resultiert aus einer Probengewinnungsprozedur und kann in mehreren Containern enthalten sein. Im Pathologielabor werden die Einsendungspräparate (Case), die aus mehreren Teilen (Parts) bestehen können, beginnend mit dem Zuschnitt, meist als Proben bezeichnet. Proben können einen oder mehrere Bearbeitungsschritte üblicherweise zu Blöcken und gefärbten Schnitten haben.

Eindeutiger Identifikator für die Probe (Einsendungspräparat). Formal oft identisch mit der Falleingangsnummer (Accession identifier).

Status der Probe hinsichtlich der Verfügbarkeit

Art der Probe

Zeitpunkt des Eingangs der Probe im Labor

Prozedur zur Probengewinnung an Patient:in

Klinische Methode (Prozedur) der Probengewinnung (an Patient:in)

Lokalisation der Körperstelle, von der die Probe stammt.

Zeitpunkt der Ent- / Abnahme der Probe

Beobachtungen zu Eigenschaften des Einsendungspräparats / der Probe, z.B. Abmessungen, Randbeziehungen, Markierungen etc., die vom Einsender mitgeteilt werden.

Prozedur der Probenbearbeitung im Labor

Kodierte Prozedur der Probenbearbeitung in der Pathologie

Referenz auf den Gegenstand der Bearbeitungsprozedur / auf die Elternprobe

Additive bei der Probenbearbeitung (Fixationsmittel, Einbettungs- und Eindeckungsmedien, Färbungen)

Textuelle Beschreibung der Probenbearbeitung.

Physikalisches Objekt, das Proben enthält oder trägt. Probenbehälter im weitesten Sinn: Einsendungsgefäß, Gewebskassette, Paraffinblock, Objektträger etc.

Identifikation des Containers, kann von Proben-ID verschieden sein

Typ des Containers

Additive im Container: Fixative im Einsendungsgefäß, Paraffin im Block, Einbettungsmedium auf dem Objektträger

Bericht über eine Beobachtung (Abschnitt eines Befundberichts), die zu einem Befund führt. Dieser Berichtsabschnitt kann generische kodierte anatomisch-pathologische Beobachtungen (Befunde) enthalten. Im Berichtsabschnitt Materialbearbeitung kann die gesamte Probengewinnung und -bearbeitung detailliert kodiert werden. Im Berichtsabschnitt Diagnostische Schlussfolgerung muss mindestens eine kodierte Beobachtung enthalten sein.

Die Intraoperative Begutachtungssektion (Schnellschnitt) enthält die intraoperative Diagnose für jedes übersandte Material, die Materialidentifikation und -beschreibung und Informationen über Proben, die für weitere Untersuchungen (z.B. Flowzytometrie, Molekularpathologie, Elektronenmikroskopie) abgeleitet wurden.

Text einer intraoperativen Beobachtung.

Semantisch annotierte atomare Einheit einer generischen pathologisch-anatomischen Beobachtung

Referenz zum eingebetteten Bild

Die Makroskopische Beurteilungssektion enthält die Beschreibung der Proben, des Zuschnitts und der makroskopische Befunde, verlinkt zu Makrobildern und Skizzen von Zuschnittssituationen. Sie sollte auch Informationen über Gewebsgele enthalten, die für zusätzliche Studien bereitgestellt oder an Biobanken gesandt wurden.

Makroskopischer Begutachtungstext

Semantisch annotierte atomare Einheit einer generischen pathologisch-anatomische Beobachtung

In eine Beobachtung eingebettetes Bild

ID des eingebetteten Bildes

Makro-Bild der Zuschnittsituation

Während des Zuschnitts des Materials werden auch Skizzen zur Schnittführung, zur Aufteilung von Gewebsstücken und zur Markierung angefertigt, um die resultierenden Blöcke und Schnitte topografisch dem Gewebe, aus dem sie entnommen wurden, zuordnen zu können.

Die Mikroskopische Begutachtungssektion enthält optional die histopathologischen Befunde des Falles. Sie sollte genutzt werden, um die Ergebnisse histochemischer und immunhistochemischer Färbungen und von bildgestützten molekularpathologischen Befunden aufzuzeichnen.

Mikroskopischer Beurteilungstext

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

ID des eingebetteten Bildes

Okularaufnahme oder WSI oder Screenshot von WSI

Region-of-interest

Ein für die jeweilige nicht-morphologische Beobachtung zutreffender LOINC-Code ist auszuwählen.

Text einer zusätzlichen spezifizierten Beobachtung

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

ID des eingebetteten Bildes

Ein der zusätzlichen, spezifizierten Beobachtung zugehöriges Dokument, z.B. ein molekularpathologischer Befundbericht, der mittels OMICS Ressourcen aus dem Untersuchungsmaterial der Pathologisch-anatomischen Begutachtung erstellt wurde.

Die Diagnostische Schlussfolgerungssektion enthält die Diagnose(n) an allen Materialien / Proben, die zu einem Fall eingesandt wurden. Diagnosen werden für jedes Material oder jede Gruppe von Materialien werden separat berichtet. Die Sektion schließt zusätzliche pathologische Befunde und Ergebnisse von unterstützenden Untersuchungen ein. Sie kann Diagramme, Bilder und virtuelle Schnitte enthalten. Für komplexe Beobachtungen, z.B. Tumorformeln, Score-Systeme, Gradings, etc. sollte auf entsprechende Profile aus anderen MII-Modulen zurückgegriffen werden. Wenn Cancer Checklists zur Befundberichtserstellung benutzt wurden, sollte dies ebenfalls in dieser Sektion eingeschlossen sein.

Text der diagnostischen Schlussfolgerung

Jede Beobachtung, die als Bestandteil einer pathologisch-anatomischen Untersuchung im Befundbericht erwähnt ist, kann zusätzlich zur textuellen Erwähnung auch semantisch annotiert, d.h. mit einem Code und einem Value in den Bericht maschinenlesbar aufgenommen werden. Die semantische Annotation kann durch beliebige Terminologiesysteme erfolgen, LOINC (für die Kodierung der Beobachtung) und SNOMED-CT (für die Kodierung des Beobachtungsergebnisses, falls es sich nicht um einen Messwert handelt), sind bevorzugt zu verwenden. Codierungsregeln für diese beiden Referenzterminologien sind unter "Practical Guidance on Uses of SNOMED CT and LOINC" (https://confluence.ihtsdotools.org/display/DOCLOINC/5.2+Practical+Guidance+on+Uses+of+SNOMED+CT+and+LOINC) hinterlegt.

In eine Beobachtung eingebettetes Bild

ID des eingebetteten Bildes

Skizze

Makro-Bild

Mikro-Bild

Region-of-interest

Logical Model for the graphical reprensentation of the respective Art-Decor Model

Der Identifikator eines Pathologiebefundberichts (z.B. E/20/12345.1) ist eineindeutig und wird meist aus der Eingangsnummer (Fall-Nummer) abgeleitet. Er sollte zusammengesetzt werden aus der Set-ID (z.B. E/20/12345), unter der alle Versionen eines Befundberichts erfasst werden, und der Versionsnummer (z.B. 1). Es ist allerdings auch möglich, einen UID (Unique identifier) oder GUID (Global Unique Identifier) zu verwenden, der keine Ableitung aus der Fallnummer darstellt. Üblicherweise wird die Fall-Nummer als Set-ID verwendet.

Status des Pathologiebefundberichts.

Zeitpunkt, an dem der Pathologiebefundbericht dokumentiert (verifiziert und freigegeben) wurde.

Auftrag zur Untersuchung einer Probe/eines Materials / einer Gruppe von Proben/einer Gruppe von Materialien.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Klinische Informationen zu einem Fall

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Fragestellung zum Fall

Anamnestische Angaben zum Fall

Überweisungsgrund

Diagnose nach gültiger ICD-10-GM

ID des Untersuchungsauftrags.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

ID einer Auftragsgruppe, bestehend aus mehreren Untersuchungsaufträgen

Auftrags-ID vom Auftraggeber vergeben

Auftrags-ID vom Auftragnehmer (Pathologie) vergeben, oft identisch mit Fall-Nr.

Status des pathologischen Untersuchungsauftrages

Beauftragte Untersuchung in kodierter Form

Arzt, der Proben eines Patienten zur pathologisch-anatomischen Untersuchung einsendet und der der Empfänger des Pathologiebefundberichtes ist.

Entnehmer einer Probe, der nicht identisch mit dem Einsender ist.

Organ oder Organteil oder eine Sammlung derselben, die als Einsendungspräparat zusammen mit dem Untersuchungsauftrag zur Bearbeitung und Begutachtung eingesandt werden.

Von einem Patienten gewonnenes Physisches Objekt oder Sammlung physischer Objekte, die als Einheit betrachtet werden, in der Pathologieeinrichtung eindeutig identifiziert sind und als Gegenstand einer oder mehrerer Prozeduren im Workflow gelten. Ein Einsendungspräparat (syn. Material, nur für Abrechnungszwecke verwendet, syn. Probe) resultiert aus einer Probengewinnungsprozedur und kann in mehreren Containern enthalten sein. Im Pathologielabor werden die Einsendungspräparate (Case), die aus mehreren Teilen (Parts) bestehen können, beginnend mit dem Zuschnitt, meist als Proben bezeichnet. Proben können einen oder mehrere Bearbeitungsschritte üblicherweise zu Blöcken und gefärbten Schnitten haben.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.