MII IG Kerndatensatz-Modul Onkologie
2027.0.0-ballot.1 -
Germany
This page is part of the MII IG Kerndatensatz-Modul Onkologie (v2027.0.0-ballot.1: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
| Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-onko/StructureDefinition/mii-pr-onko-befund | Version: 2027.0.0-ballot.1 | |||
| Active as of 2026-09-15 | Computable Name: MII_PR_Onko_Befund | |||
Histologie: Befund. Vollständiger Befundbericht des Pathologen.
This profile describes a pathology report in the oncology context.
Since the data originate from local tumour documentation systems, a large part of the reports will be available as plain text only.
Pathology reporting MAY also be carried out within the MII via the pathology report. In that case, individual observations can be coded in a structured way as patho findings using LOINC or SNOMED. See MII PR Patho Report (Pathologie-Befund module).
Mapping dataset to FHIR
The mapping of the dataset fields is documented in the logical model: MII LM Onkologie.
Mapping Einheitlicher onkologischer Basisdatensatz (oBDS) to FHIR
The oBDS mappings are recorded in the artefact view of this profile: MII PR Onkologie Befund.
Examples
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots, and their representations.
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource |
![]() ![]() ![]() |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
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?! | 0..* | Extension | Extensions that cannot be ignored |
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S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() |
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S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested |
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?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Pathology report code Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
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0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
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SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 |
![]() ![]() |
SΣ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
![]() ![]() |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
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S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on |
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S | 1..1 | string | Befund als Freitext |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
![]() ![]() |
||||
![]() ![]() ![]() |
S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() |
![]() ![]() ![]() |
S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested |
![]() ![]() |
S | 1..1 | CodeableConcept | Pathology report code |
![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
![]() ![]() ![]() ![]() |
S | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 |
![]() ![]() |
S | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
![]() ![]() |
S | 0..1 | Reference(Encounter) | Health care event when test ordered |
![]() ![]() |
S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on |
![]() ![]() |
S | 1..1 | string | Befund als Freitext |
Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
Σ | 0..1 | instant | When the resource version last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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Σ | 0..* | Identifier | Business identifier for report | ||||
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S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() | ||||
![]() ![]() ![]() |
S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested | ||||
![]() ![]() |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
![]() ![]() |
Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Pathology report code Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Representation defined by the system | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() |
SΣ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
![]() ![]() |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
![]() ![]() |
Σ | 0..1 | Clinically relevant time/time-period for report | |||||
![]() ![]() ![]() |
dateTime | |||||||
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Period | |||||||
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Σ | 0..1 | instant | DateTime this version was made | ||||
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
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S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on | ||||
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0..* | Reference(Observation) | Observations | |||||
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0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
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Σ | 0..* | BackboneElement | Key images associated with this report | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() |
0..1 | string | Comment about the image (e.g. explanation) | |||||
![]() ![]() ![]() |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
![]() ![]() |
S | 1..1 | string | Befund als Freitext | ||||
![]() ![]() |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
![]() ![]() |
0..* | Attachment | Entire report as issued | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Summary
Mandatory: 6 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource |
![]() ![]() ![]() |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored |
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() |
![]() ![]() ![]() |
S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested |
![]() ![]() |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Pathology report code Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Version of the system - if relevant | |
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() |
0..1 | boolean | If this coding was chosen directly by the user | |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 |
![]() ![]() |
SΣ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
![]() ![]() |
SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered |
![]() ![]() |
S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on |
![]() ![]() |
S | 1..1 | string | Befund als Freitext |
Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Differential View
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() |
|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
![]() ![]() |
||||
![]() ![]() ![]() |
S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() |
![]() ![]() ![]() |
S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested |
![]() ![]() |
S | 1..1 | CodeableConcept | Pathology report code |
![]() ![]() ![]() |
S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
![]() ![]() ![]() ![]() |
S | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org |
![]() ![]() ![]() ![]() ![]() |
S | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 |
![]() ![]() |
S | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient |
![]() ![]() |
S | 0..1 | Reference(Encounter) | Health care event when test ordered |
![]() ![]() |
S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on |
![]() ![]() |
S | 1..1 | string | Befund als Freitext |
Documentation for this format | ||||
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: ![]() ![]() | ||||
|---|---|---|---|---|---|---|---|---|
![]() |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Version specific identifier | ||||
![]() ![]() ![]() |
Σ | 0..1 | instant | When the resource version last changed | ||||
![]() ![]() ![]() |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
![]() ![]() ![]() |
SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
![]() ![]() ![]() |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() |
Σ | 0..* | Identifier | Business identifier for report | ||||
![]() ![]() |
S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested Slice: Unordered, Open by type:$this.resolve() | ||||
![]() ![]() ![]() |
S | 0..1 | Reference(MII PR Onkologie Tumorkonferenz) | What was requested | ||||
![]() ![]() |
?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
![]() ![]() |
Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
![]() ![]() |
SΣ | 1..1 | CodeableConcept | Pathology report code Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() |
SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this | ||||
![]() ![]() ![]() ![]() |
SΣ | 1..1 | Coding | Code defined by a terminology system Required Pattern: At least the following | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
SΣ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 22034-3 | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Representation defined by the system | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() |
Σ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() |
SΣ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient | ||||
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SΣ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
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Σ | 0..1 | Clinically relevant time/time-period for report | |||||
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dateTime | |||||||
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Period | |||||||
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Σ | 0..1 | instant | DateTime this version was made | ||||
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service | ||||
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Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
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S | 0..* | Reference(MII PR Onkologie Specimen | Specimen) | Specimens this report is based on | ||||
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0..* | Reference(Observation) | Observations | |||||
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0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
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Σ | 0..* | BackboneElement | Key images associated with this report | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Comment about the image (e.g. explanation) | |||||
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Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
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S | 1..1 | string | Befund als Freitext | ||||
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0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
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0..* | Attachment | Entire report as issued | |||||
Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.meta.security | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.meta.tag | Base | example | Common Tags | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Summary
Mandatory: 6 elements
Must-Support: 12 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron