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

Context and references

The module Pathology Report maps pathology findings that are typically produced in the pathology facility of a hospital. These reports play a central role in several use cases of the MII:

• Pathology reports from routine examinations are essential for diagnosis and therapy monitoring in most diseases

• Pathology reports are an important component of many clinical studies

References within the MII

A pathology report is always assigned to the person from whom the specimens were taken, and is related to an encounter at a healthcare facility. This encounter is a pathology-facility-specific (department) contact, the so-called submission, which groups all examination requests for specimens of one person that were taken in a temporal and professional context. This encounter does not have to be identical to the examination request. If a specimen of a case is stored in a biobank for further examinations, that specimen can be represented with the profiles of the module Biospecimen. The results of a pathology report can be reused as individual elements in various other modules, e.g. for tumor documentation.

Conversely, reports from other disciplines (e.g. from the modules Molecular Genetic Report or Laboratory) can be included in pathology reports in whole or in part and interpreted in the sense of a synoptic assessment.

Furthermore, a relationship to the module Diagnosis may exist. A diagnosis can be referenced by an examination request (e.g. as part of the clinical information / history of present illness). It can, however, also reference a report itself if that report is to serve as evidence, e.g. for the staging of the diagnosis made.

References outside the MII

Since pathology systems can be so-called subsystems within the hospital, compatibility with ISiK is essential for the implementation of the pathology profiles of the Medical Informatics Initiative. For bundling the pathology resource instances, a Composition/Bundle is used which inherits from the ISiK profile ISiKBerichtSubsysteme.