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

The identifier of a pathology report (e.g. E/20/12345.1) is unique and is usually derived from the accession number (case number). It should be composed of the set ID (e.g. E/20/12345), under which all versions of a report are recorded, and the version number (e.g. 1). It is, however, also possible to use a UID (unique identifier) or GUID (global unique identifier) that is not derived from the case number. Usually the case number is used as the set ID.

Status of the pathology report.

Date and time at which the pathology report was documented (verified and released).

Request for the examination of a specimen/material or of a group of specimens/materials.

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.

Clinical information about the case

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.

Clinical question for the case

History of present illness for the case

Reason for referral

Diagnosis according to the valid ICD-10-GM

ID of the examination request.

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 of an order group consisting of several examination requests

Order ID assigned by the placer

Order ID assigned by the filler (pathology), often identical to the case number

Status of the pathology examination request

Ordered examination in coded form

Doctor who sends specimens of a patient for pathological-anatomical examination and who is the recipient of the pathology report.

Sample collector who is not identical to the sender.

Organ or part of an organ or a collection thereof that is sent in as a submitted specimen together with the examination request for processing and assessment.

Physical object or collection of physical objects obtained from a patient that are regarded as a unit, are uniquely identified within the pathology facility and are the subject of one or more procedures in the workflow. A submitted specimen (syn. material, used for billing purposes only, syn. sample) results from a specimen collection procedure and may be contained in several containers. In the pathology laboratory the submitted specimens (case), which may consist of several parts, are usually called specimens from grossing onwards. Specimens may undergo one or more processing steps, usually into blocks and stained sections.

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.

Unique identifier for the specimen (submitted specimen). Formally often identical to the accession number (accession identifier).

Status of the specimen with regard to availability

Type of the specimen

Date and time of specimen receipt in the laboratory

Procedure for specimen collection from the patient

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.

Clinical method (procedure) of specimen collection (from the patient)

Location of the body site from which the specimen originates.

Date and time of specimen collection

Observations on properties of the submitted specimen / of the sample, e.g. dimensions, margin relationships, markings etc., that are communicated by the sender.

Procedure of specimen processing in the laboratory

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.

Coded procedure of specimen processing in pathology

Reference to the object of the processing procedure / to the parent specimen

Additives used in specimen processing (fixatives, embedding and mounting media, stains)

Textual description of the specimen processing.

Physical object that contains or carries specimens. Specimen container in the broadest sense: submission container, tissue cassette, paraffin block, slide, 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.

Identification of the container, may differ from the specimen ID

Type of the container

Additives in the container: fixatives in the submission container, paraffin in the block, mounting medium on the slide

Report on an observation (section of a pathology report) that leads to a finding. This report section may contain generic coded anatomical-pathological observations (findings). In the report section Specimen processing, the entire specimen collection and processing can be coded in detail. The report section Diagnostic conclusion must contain at least one coded observation.

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.

The intraoperative assessment section (frozen section) contains the intraoperative diagnosis for each submitted material, the material identification and description, and information on specimens derived for further examinations (e.g. flow cytometry, molecular pathology, electron microscopy).

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 of an intraoperative observation.

Semantically annotated atomic unit of a generic pathological-anatomical observation

Reference to the embedded image

The macroscopic assessment section contains the description of the specimens, of the grossing and of the macroscopic findings, linked to macro images and sketches of grossing situations. It should also contain information on tissue samples that were provided for additional studies or sent to biobanks.

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.

Macroscopic assessment text

Semantically annotated atomic unit of a generic pathological-anatomical observation

Image embedded in an observation

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 of the embedded image

Macro image of the grossing situation

During grossing of the material, sketches of the cutting, of the division of tissue pieces and of the markings are also produced, so that the resulting blocks and sections can be topographically assigned to the tissue from which they were taken.

The microscopic assessment section optionally contains the histopathological findings of the case. It should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular pathology findings.

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.

Microscopic assessment text

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

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 of the embedded image

Eyepiece photograph or WSI or screenshot of a WSI

Region-of-interest

A LOINC code applicable to the respective non-morphological observation must be selected.

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 of an additional specified observation

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

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 of the embedded image

A document belonging to the additional specified observation, e.g. a molecular pathology report created by means of OMICS resources from the material examined in the pathological-anatomical assessment.

The diagnostic conclusion section contains the diagnosis(es) for all materials / specimens submitted for a case. Diagnoses are reported separately for each material or each group of materials. The section includes additional pathological findings and results of supporting examinations. It may contain diagrams, images and virtual slides. For complex observations, e.g. tumor formulas, scoring systems, gradings, etc., the corresponding profiles from other MII modules should be used. If cancer checklists were used to create the report, this should also be included in this section.

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 of the diagnostic conclusion

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

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 of the embedded image

Sketch

Macro image

Micro image

Region-of-interest

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

The identifier of a pathology report (e.g. E/20/12345.1) is unique and is usually derived from the accession number (case number). It should be composed of the set ID (e.g. E/20/12345), under which all versions of a report are recorded, and the version number (e.g. 1). It is, however, also possible to use a UID (unique identifier) or GUID (global unique identifier) that is not derived from the case number. Usually the case number is used as the set ID.

Status of the pathology report.

Date and time at which the pathology report was documented (verified and released).

Request for the examination of a specimen/material or of a group of specimens/materials.

Clinical information about the case

Clinical question for the case

History of present illness for the case

Reason for referral

Diagnosis according to the valid ICD-10-GM

ID of the examination request.

ID of an order group consisting of several examination requests

Order ID assigned by the placer

Order ID assigned by the filler (pathology), often identical to the case number

Status of the pathology examination request

Ordered examination in coded form

Doctor who sends specimens of a patient for pathological-anatomical examination and who is the recipient of the pathology report.

Sample collector who is not identical to the sender.

Organ or part of an organ or a collection thereof that is sent in as a submitted specimen together with the examination request for processing and assessment.

Physical object or collection of physical objects obtained from a patient that are regarded as a unit, are uniquely identified within the pathology facility and are the subject of one or more procedures in the workflow. A submitted specimen (syn. material, used for billing purposes only, syn. sample) results from a specimen collection procedure and may be contained in several containers. In the pathology laboratory the submitted specimens (case), which may consist of several parts, are usually called specimens from grossing onwards. Specimens may undergo one or more processing steps, usually into blocks and stained sections.

Unique identifier for the specimen (submitted specimen). Formally often identical to the accession number (accession identifier).

Status of the specimen with regard to availability

Type of the specimen

Date and time of specimen receipt in the laboratory

Procedure for specimen collection from the patient

Clinical method (procedure) of specimen collection (from the patient)

Location of the body site from which the specimen originates.

Date and time of specimen collection

Observations on properties of the submitted specimen / of the sample, e.g. dimensions, margin relationships, markings etc., that are communicated by the sender.

Procedure of specimen processing in the laboratory

Coded procedure of specimen processing in pathology

Reference to the object of the processing procedure / to the parent specimen

Additives used in specimen processing (fixatives, embedding and mounting media, stains)

Textual description of the specimen processing.

Physical object that contains or carries specimens. Specimen container in the broadest sense: submission container, tissue cassette, paraffin block, slide, etc.

Identification of the container, may differ from the specimen ID

Type of the container

Additives in the container: fixatives in the submission container, paraffin in the block, mounting medium on the slide

Report on an observation (section of a pathology report) that leads to a finding. This report section may contain generic coded anatomical-pathological observations (findings). In the report section Specimen processing, the entire specimen collection and processing can be coded in detail. The report section Diagnostic conclusion must contain at least one coded observation.

The intraoperative assessment section (frozen section) contains the intraoperative diagnosis for each submitted material, the material identification and description, and information on specimens derived for further examinations (e.g. flow cytometry, molecular pathology, electron microscopy).

Text of an intraoperative observation.

Semantically annotated atomic unit of a generic pathological-anatomical observation

Reference to the embedded image

The macroscopic assessment section contains the description of the specimens, of the grossing and of the macroscopic findings, linked to macro images and sketches of grossing situations. It should also contain information on tissue samples that were provided for additional studies or sent to biobanks.

Macroscopic assessment text

Semantically annotated atomic unit of a generic pathological-anatomical observation

Image embedded in an observation

ID of the embedded image

Macro image of the grossing situation

During grossing of the material, sketches of the cutting, of the division of tissue pieces and of the markings are also produced, so that the resulting blocks and sections can be topographically assigned to the tissue from which they were taken.

The microscopic assessment section optionally contains the histopathological findings of the case. It should be used to record the results of histochemical and immunohistochemical stains and of image-based molecular pathology findings.

Microscopic assessment text

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

ID of the embedded image

Eyepiece photograph or WSI or screenshot of a WSI

Region-of-interest

A LOINC code applicable to the respective non-morphological observation must be selected.

Text of an additional specified observation

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

ID of the embedded image

A document belonging to the additional specified observation, e.g. a molecular pathology report created by means of OMICS resources from the material examined in the pathological-anatomical assessment.

The diagnostic conclusion section contains the diagnosis(es) for all materials / specimens submitted for a case. Diagnoses are reported separately for each material or each group of materials. The section includes additional pathological findings and results of supporting examinations. It may contain diagrams, images and virtual slides. For complex observations, e.g. tumor formulas, scoring systems, gradings, etc., the corresponding profiles from other MII modules should be used. If cancer checklists were used to create the report, this should also be included in this section.

Text of the diagnostic conclusion

Every observation mentioned in the pathology report as part of a pathological-anatomical examination can, in addition to the textual mention, also be annotated semantically, i.e. included in the report in machine-readable form with a code and a value. The semantic annotation may use any terminology system; LOINC (for coding the observation) and SNOMED CT (for coding the observation result, unless it is a measured value) are to be used preferentially. Coding rules for these two reference terminologies are provided under "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).

Image embedded in an observation

ID of the embedded image

Sketch

Macro image

Micro image

Region-of-interest

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

The identifier of a pathology report (e.g. E/20/12345.1) is unique and is usually derived from the accession number (case number). It should be composed of the set ID (e.g. E/20/12345), under which all versions of a report are recorded, and the version number (e.g. 1). It is, however, also possible to use a UID (unique identifier) or GUID (global unique identifier) that is not derived from the case number. Usually the case number is used as the set ID.

Status of the pathology report.

Date and time at which the pathology report was documented (verified and released).

Request for the examination of a specimen/material or of a group of specimens/materials.

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.

Clinical information about the case

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.

Clinical question for the case

History of present illness for the case

Reason for referral

Diagnosis according to the valid ICD-10-GM

ID of the examination request.

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 of an order group consisting of several examination requests

Order ID assigned by the placer

Order ID assigned by the filler (pathology), often identical to the case number

Status of the pathology examination request

Ordered examination in coded form

Doctor who sends specimens of a patient for pathological-anatomical examination and who is the recipient of the pathology report.

Sample collector who is not identical to the sender.

Organ or part of an organ or a collection thereof that is sent in as a submitted specimen together with the examination request for processing and assessment.

Physical object or collection of physical objects obtained from a patient that are regarded as a unit, are uniquely identified within the pathology facility and are the subject of one or more procedures in the workflow. A submitted specimen (syn. material, used for billing purposes only, syn. sample) results from a specimen collection procedure and may be contained in several containers. In the pathology laboratory the submitted specimens (case), which may consist of several parts, are usually called specimens from grossing onwards. Specimens may undergo one or more processing steps, usually into blocks and stained sections.

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.