MII IG Molekulares Tumorboard DE v2025

Molekular-Pathologie-Befund: DiagnosticReport

Inhalt

Dieses Profil beschreibt den Molekular-Pathologie-Befund.

Verknüpfungen zu anderen Ressourcen

Zeitliche Zuordnung im Verlauf

Name	Status	Version	Canonical	Basis
MII_PR_MTB_Molecular_Pathology_Report	draft	2024.0.0-ballot	https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-molecular-pathology-report	http://hl7.org/fhir/StructureDefinition/DiagnosticReport

Inhalt

MII_PR_MTB_Molecular_Pathology_Report (DiagnosticReport)	I		DiagnosticReport	There are no (further) constraints on this element Element id DiagnosticReport Short description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate names Report, Test, Result, Results, Labs, Laboratory Definition The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports. Comments This is intended to capture a single report and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing. Data type DiagnosticReport Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` dom-6: A resource should have narrative for robust management text.`div`.exists() Mappings rim: Entity. Role, or Act workflow: Event v2: ORU -> OBR rim: Observation[classCode=OBS, moodCode=EVN]
id	Σ	0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	S Σ	0..1	Meta	There are no (further) constraints on this element Element id DiagnosticReport.meta Short description Metadata about the resource Definition The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.meta.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.meta.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id DiagnosticReport.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
lastUpdated	Σ	0..1	instant	There are no (further) constraints on this element Element id DiagnosticReport.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
source	Σ	0..1	uri	There are no (further) constraints on this element Element id DiagnosticReport.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
profile	S Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id DiagnosticReport.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id DiagnosticReport.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id DiagnosticReport.meta.tag Short description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id DiagnosticReport.implicitRules Short description A set of rules under which this content was created Definition A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Comments Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
language		0..1	codeBinding	There are no (further) constraints on this element Element id DiagnosticReport.language Short description Language of the resource content Definition The base language in which the resource is written. Comments Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())`
text		0..1	Narrative	There are no (further) constraints on this element Element id DiagnosticReport.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Comments Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id DiagnosticReport.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. Comments This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. Data type Resource Mappings rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it 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 is allowed to 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element id DiagnosticReport.identifier Short description Business identifier for report Alternate names ReportID, Filler ID, Placer ID Definition Identifiers assigned to this report by the performer or other systems. Requirements Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context. Comments Usually assigned by the Information System of the diagnostic service provider (filler id). Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.identifier w5: FiveWs.identifier v2: OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4 rim: id
basedOn		0..*	Reference(CarePlan \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest)	There are no (further) constraints on this element Element id DiagnosticReport.basedOn Short description What was requested Alternate names Request Definition Details concerning a service requested. Requirements This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. Comments Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports. Data type Reference(CarePlan \| ImmunizationRecommendation \| MedicationRequest \| NutritionOrder \| ServiceRequest) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.basedOn v2: ORC? OBR-2/3? rim: outboundRelationship[typeCode=FLFS].target
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element id DiagnosticReport.status Short description registered \| partial \| preliminary \| final + Definition The status of the diagnostic report. Requirements Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Data type code Binding The status of the diagnostic report. DiagnosticReportStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.status w5: FiveWs.status v2: OBR-25 (not 1:1 mapping) rim: statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise"
category	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id DiagnosticReport.category Short description Service category Alternate names Department, Sub-department, Service, Discipline Definition A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Comments Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code. Data type CodeableConcept Binding Codes for diagnostic service sections. DiagnosticServiceSectionCodes (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.class v2: OBR-24 rim: inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code
code	Σ	1..1	CodeableConceptBinding	There are no (further) constraints on this element Element id DiagnosticReport.code Short description Name/Code for this diagnostic report Alternate names Type Definition A code or name that describes this diagnostic report. Data type CodeableConcept Binding Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.code w5: FiveWs.what[x] v2: OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel) rim: code
subject	S Σ	1..1	Reference(Patient)	Element id DiagnosticReport.subject Short description The subject of the report - usually, but not always, the patient Alternate names Patient Definition The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. Requirements SHALL know the subject context. Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.subject w5: FiveWs.subject[x] v2: PID-3 (no HL7 v2 mapping for Group or Device) rim: participation[typeCode=SBJ] w5: FiveWs.subject
encounter	Σ	0..1	Reference(Encounter)	There are no (further) constraints on this element Element id DiagnosticReport.encounter Short description Health care event when test ordered Alternate names Context Definition The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. Requirements Links the request to the Encounter context. Comments This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests). Data type Reference(Encounter) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.encounter w5: FiveWs.context v2: PV1-19 rim: inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]
effective[x]	Σ	0..1		There are no (further) constraints on this element Element id DiagnosticReport.effective[x] Short description Clinically relevant time/time-period for report Alternate names Observation time, Effective Time, Occurrence Definition The time or time-period the observed values are related to. When the subject of the report is a patient, this is usually either the time of the procedure or of specimen collection(s), but very often the source of the date/time is not known, only the date/time itself. Requirements Need to know where in the patient history to file/present this report. Comments If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic. Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.occurrence[x] w5: FiveWs.done[x] v2: OBR-7 rim: effectiveTime
effectiveDateTime			dateTime	There are no (further) constraints on this element Data type dateTime
effectivePeriod			Period	There are no (further) constraints on this element Data type Period
issued	S Σ	0..1	instant	Element id DiagnosticReport.issued Short description Erstellungsdatum Alternate names Date published, Date Issued, Date Verified Definition Erstellungsdatum des Berichts Requirements Clinicians need to be able to check the date that the report was released. Comments May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings w5: FiveWs.recorded v2: OBR-22 rim: participation[typeCode=VRF or AUT].time
performer	Σ	0..*	Reference(Organization)	Element id DiagnosticReport.performer Short description Institut Alternate names Laboratory, Service, Practitioner, Department, Company, Authorized by, Director Definition Berichtendes Institut Requirements Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Comments This is not necessarily the source of the atomic data items or the entity that interpreted the results. It is the entity that takes responsibility for the clinical report. Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer.actor w5: FiveWs.actor v2: PRT-8 (where this PRT-4-Participation = "PO") rim: .participation[typeCode=PRF]
resultsInterpreter	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	There are no (further) constraints on this element Element id DiagnosticReport.resultsInterpreter Short description Primary result interpreter Alternate names Analyzed by, Reported by Definition The practitioner or organization that is responsible for the report's conclusions and interpretations. Requirements Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis. Comments Might not be the same entity that takes responsibility for the clinical report. Data type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings workflow: Event.performer.actor w5: FiveWs.actor v2: OBR-32, PRT-8 (where this PRT-4-Participation = "PI") rim: .participation[typeCode=PRF]
specimen		0..*	Reference(Specimen)	Element id DiagnosticReport.specimen Short description Probe Definition Dem Bericht zugrunde liegende Probe Requirements Need to be able to report information about the collected specimens on which the report is based. Comments If the specimen is sufficiently specified with a code in the test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per observation or group. Data type Reference(Specimen) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: SPM rim: participation[typeCode=SBJ]
result		0..*	Reference(Observation)	Element id DiagnosticReport.result Short description Diagnostik Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Art der Diagnostik Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Comments Observations can contain observations. Data type Reference(Observation) Sliced: Unordered, Open, by $this.resolve()(Profile) Slices für verschiedene Inhalte eines Molekularpathologischen Reports. Diese Slices sind beliebig erweiterbar Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBXs rim: outboundRelationship[typeCode=COMP].target
Immunhistochemie	S	0..*	Reference(MII_PR_MTB_Immunohistochemistry)	Element id DiagnosticReport.result:Immunhistochemie Short description Immunhistochemie Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Observations that are part of this diagnostic report. Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Comments Observations can contain observations. Data type Reference(MII_PR_MTB_Immunohistochemistry) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBXs rim: outboundRelationship[typeCode=COMP].target
InSituHybridisierung	S	0..*	Reference(MII_PR_MTB_Biomarker_InSituHybridization)	Element id DiagnosticReport.result:InSituHybridisierung Short description Gewebasierte In-Situ-Hybridisierung Alternate names Data, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer Definition Observations that are part of this diagnostic report. Requirements Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Comments Observations can contain observations. Data type Reference(MII_PR_MTB_Biomarker_InSituHybridization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBXs rim: outboundRelationship[typeCode=COMP].target
imagingStudy		0..*	Reference(ImagingStudy)	There are no (further) constraints on this element Element id DiagnosticReport.imagingStudy Short description Reference to full details of imaging associated with the diagnostic report Definition One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. Comments ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided. Data type Reference(ImagingStudy) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]
media	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element id DiagnosticReport.media Short description Key images associated with this report Alternate names DICOM, Slides, Scans Definition A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). Requirements Many diagnostic services include images in the report as part of their service. Data type BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX? rim: outboundRelationship[typeCode=COMP].target
id		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.media.id Short description Unique id for inter-element referencing Definition Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. Data type string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.media.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: n/a
modifierExtension	Σ ?! I	0..*	Extension	There are no (further) constraints on this element Element id DiagnosticReport.media.modifierExtension Short description Extensions that cannot be ignored even if unrecognized Alternate names extensions, user content, modifiers Definition 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). Requirements 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. Comments 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. Data type Extension Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ext-1: Must have either extensions or value[x], not both `extension.exists() != value.exists()` Mappings rim: N/A
comment		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.media.comment Short description Comment about the image (e.g. explanation) Definition A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features. Requirements The provider of the report should make a comment about each image included in the report. Comments The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value
link	Σ	1..1	Reference(Media)	There are no (further) constraints on this element Element id DiagnosticReport.media.link Short description Reference to the image source Definition Reference to the image source. Data type Reference(Media) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: .value.reference
conclusion		0..1	string	There are no (further) constraints on this element Element id DiagnosticReport.conclusion Short description Clinical conclusion (interpretation) of test results Alternate names Report Definition Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Requirements Need to be able to provide a conclusion that is not lost among the basic result data. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX rim: inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)
conclusionCode		0..*	CodeableConcept	There are no (further) constraints on this element Element id DiagnosticReport.conclusionCode Short description Codes for the clinical conclusion of test results Definition One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Data type CodeableConcept Binding Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX rim: inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)
presentedForm		0..*	Attachment	There are no (further) constraints on this element Element id DiagnosticReport.presentedForm Short description Entire report as issued Definition Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. Requirements Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. Comments "application/pdf" is recommended as the most reliable and interoperable in this context. Data type Attachment Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings v2: OBX rim: text (type=ED)

Molecular pathology report

Feldname	Kurzbeschreibung
DiagnosticReport.meta
DiagnosticReport.meta.profile
DiagnosticReport.subject
DiagnosticReport.issued	Erstellungsdatum
DiagnosticReport.result:Immunhistochemie	Immunhistochemie
DiagnosticReport.result:InSituHybridisierung	Gewebasierte In-Situ-Hybridisierung

<StructureDefinition xmlns="http://hl7.org/fhir">
    <id value="mii-pr-mtb-molecular-pathology-report" />
    <url value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-molecular-pathology-report" />
    <version value="2024.0.0-ballot" />
    <name value="MII_PR_MTB_Molecular_Pathology_Report" />
    <title value="MII PR MTB Molecular Pathology Report" />
    <status value="draft" />
    <publisher value="Medizininformatik Initiative" />
    <contact>
        <telecom>
            <system value="url" />
            <value value="https://www.medizininformatik-initiative.de" />
        </telecom>
    </contact>
    <description value="Molecular pathology report" />
    <fhirVersion value="4.0.1" />
    <kind value="resource" />
    <abstract value="false" />
    <type value="DiagnosticReport" />
    <baseDefinition value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport" />
    <derivation value="constraint" />
    <differential>
        <element id="DiagnosticReport.meta">
            <path value="DiagnosticReport.meta" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.meta.profile">
            <path value="DiagnosticReport.meta.profile" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.subject">
            <path value="DiagnosticReport.subject" />
            <min value="1" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Patient" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.issued">
            <path value="DiagnosticReport.issued" />
            <short value="Erstellungsdatum" />
            <definition value="Erstellungsdatum des Berichts" />
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.performer">
            <path value="DiagnosticReport.performer" />
            <short value="Institut" />
            <definition value="Berichtendes Institut" />
            <type>
                <code value="Reference" />
                <targetProfile value="http://hl7.org/fhir/StructureDefinition/Organization" />
            </type>
        </element>
        <element id="DiagnosticReport.specimen">
            <path value="DiagnosticReport.specimen" />
            <short value="Probe" />
            <definition value="Dem Bericht zugrunde liegende Probe" />
        </element>
        <element id="DiagnosticReport.result">
            <path value="DiagnosticReport.result" />
            <slicing>
                <discriminator>
                    <type value="profile" />
                    <path value="$this.resolve()" />
                </discriminator>
                <description value="Slices f&#252;r verschiedene Inhalte eines Molekularpathologischen Reports. Diese Slices sind beliebig erweiterbar" />
                <rules value="open" />
            </slicing>
            <short value="Diagnostik" />
            <definition value="Art der Diagnostik" />
        </element>
        <element id="DiagnosticReport.result:Immunhistochemie">
            <path value="DiagnosticReport.result" />
            <sliceName value="Immunhistochemie" />
            <short value="Immunhistochemie" />
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-immunohistochemistry" />
            </type>
            <mustSupport value="true" />
        </element>
        <element id="DiagnosticReport.result:InSituHybridisierung">
            <path value="DiagnosticReport.result" />
            <sliceName value="InSituHybridisierung" />
            <short value="Gewebasierte In-Situ-Hybridisierung" />
            <min value="0" />
            <max value="*" />
            <type>
                <code value="Reference" />
                <targetProfile value="https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-insituhybridization" />
            </type>
            <mustSupport value="true" />
        </element>
    </differential>
</StructureDefinition>

{
    "resourceType": "StructureDefinition",
    "id": "mii-pr-mtb-molecular-pathology-report",
    "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-molecular-pathology-report",
    "version": "2024.0.0-ballot",
    "name": "MII_PR_MTB_Molecular_Pathology_Report",
    "title": "MII PR MTB Molecular Pathology Report",
    "status": "draft",
    "publisher": "Medizininformatik Initiative",
    "contact":  [
        {
            "telecom":  [
                {
                    "system": "url",
                    "value": "https://www.medizininformatik-initiative.de"
                }
            ]
        }
    ],
    "description": "Molecular pathology report",
    "fhirVersion": "4.0.1",
    "kind": "resource",
    "abstract": false,
    "type": "DiagnosticReport",
    "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
    "derivation": "constraint",
    "differential": {
        "element":  [
            {
                "id": "DiagnosticReport.meta",
                "path": "DiagnosticReport.meta",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.meta.profile",
                "path": "DiagnosticReport.meta.profile",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.subject",
                "path": "DiagnosticReport.subject",
                "min": 1,
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Patient"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.issued",
                "path": "DiagnosticReport.issued",
                "short": "Erstellungsdatum",
                "definition": "Erstellungsdatum des Berichts",
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.performer",
                "path": "DiagnosticReport.performer",
                "short": "Institut",
                "definition": "Berichtendes Institut",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "http://hl7.org/fhir/StructureDefinition/Organization"
                        ]
                    }
                ]
            },
            {
                "id": "DiagnosticReport.specimen",
                "path": "DiagnosticReport.specimen",
                "short": "Probe",
                "definition": "Dem Bericht zugrunde liegende Probe"
            },
            {
                "id": "DiagnosticReport.result",
                "path": "DiagnosticReport.result",
                "slicing": {
                    "discriminator":  [
                        {
                            "type": "profile",
                            "path": "$this.resolve()"
                        }
                    ],
                    "rules": "open",
                    "description": "Slices für verschiedene Inhalte eines Molekularpathologischen Reports. Diese Slices sind beliebig erweiterbar"
                },
                "short": "Diagnostik",
                "definition": "Art der Diagnostik"
            },
            {
                "id": "DiagnosticReport.result:Immunhistochemie",
                "path": "DiagnosticReport.result",
                "sliceName": "Immunhistochemie",
                "short": "Immunhistochemie",
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-immunohistochemistry"
                        ]
                    }
                ],
                "mustSupport": true
            },
            {
                "id": "DiagnosticReport.result:InSituHybridisierung",
                "path": "DiagnosticReport.result",
                "sliceName": "InSituHybridisierung",
                "short": "Gewebasierte In-Situ-Hybridisierung",
                "min": 0,
                "max": "*",
                "type":  [
                    {
                        "code": "Reference",
                        "targetProfile":  [
                            "https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-insituhybridization"
                        ]
                    }
                ],
                "mustSupport": true
            }
        ]
    }
}

MII PR MTB Molecular Pathology Report

Mapping Datensatz zu FHIR

Datensatz	Erklaerung	FHIR
RNA Fusion	RNA Fusion	MII_PR_MTB_RNA_Seq
Varianten ID	Varianten ID	MII_PR_MTB_RNA_Seq.component[variation-code]
Entrez ID	Entrez ID	MII_PR_MTB_RNA_Seq.component[variation-code]
Ensemble ID	Ensemble ID	MII_PR_MTB_RNA_Seq.component[variation-code]
Gen	Gen	MII_PR_MTB_RNA_Seq.component[gene-studied]
Transcript ID	Transcript ID	MII_PR_MTB_RNA_Seq.component[transcript-id]
Transcripts Per Million	Transcripts Per Million	MII_PR_MTB_RNA_Seq.component[transcripts-per-million]
Tissue Corrected Expression	Tissue Corrected Expression	MII_PR_MTB_RNA_Seq.component[tissue-corrected-expression]
Raw counts	Raw counts	MII_PR_MTB_RNA_Seq.component[raw-counts]
Library size	Library size	MII_PR_MTB_RNA_Seq.component[library-size]
Cohort ranking	Cohort ranking	MII_PR_MTB_RNA_Seq.component[cohort-ranking]

Suchparameter

Folgende Suchparameter sind für das Modul Onkologie relevant, auch in Kombination:

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/Observation?_id=12345

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "_profile" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-mtb/StructureDefinition/mii-pr-mtb-molecular-pathology-report

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "subject" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?subject=Patient/example-mii-mtb-patient

Anwendungshinweise: Weitere Informationen zur Suche nach "subject" finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Der Suchparameter "issued" MUSS unterstützt werden:

Beispiele:

GET [base]/DiagnosticReport?issued=2025-05-22

Anwendungshinweise: Weitere Informationen zur Suche nach "issued" finden sich in der FHIR-Basisspezifikation - Abschnitt "date".

Beispiele