MII IG Pathologie-Befund DE v2026
Pathologie-Befund (DiagnosticReport)
Beschreibung
Das Profil MII PR Patho Report der Ressource DiagnosticReport bildet den kompletten Befundbericht ab, ohne Dokumenteigenschaften zu besitzen (siehe MII-PR-Patho-Composition).
Es stellt hochstrukturierte Untersuchungsergebnisse einschließlich menschenlesbarer Texte (Narrative) dar, die zu „Panels“ von Einzeluntersuchungen gehören. Es sammelt und organisiert PathologyFindings für auch komplexe Einzelergebnisse und kann weitere Informationen zum Untersuchungspanel, z.B. auch klinische Informationen und Probeninformationen referenzieren. Ein vollständiger formatierter Befundtext sollte Teil des MII PR Patho Report sein.
Die wichtigsten Besonderheiten des MII PR Patho Report sind:
- die Möglichkeit, zusätzlichen klinischen Kontext, z.B. eine Mischung von Ergebnissen aus Einzelbeobachtungen, Bildern, Texten und formatisierten Darstellungen einzubinden,
- die Möglichkeit, Informationen zu mehreren Proben (hier die klinischerseits eingesandten Proben) zu einzubinden,
- und die Möglichkeit, eine zusammenfassende Bewertung, die Conclusion, sowie einen oder mehrere Conclusion.codes abzubilden, die nicht identisch mit PathologyFindings sind.
Das MII PR Patho Report bildet als Entry in der Section "patho-diagnostic-report" des Profils MII PR Patho Composition den Kern eines persistenten Dokuments "Pathologiebefundbericht".
| Name | Canonical |
|---|---|
| MII_PR_Patho_Report | https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report |
| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe 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. 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.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies where the resource comes from DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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. canonical(StructureDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags applied to this resource DefinitionTags 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. 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. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Verwandter Bericht Alternate namesextensions, user content DefinitionVerweis auf Vorbefunde Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. 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. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Set-ID | S Σ | 1..1 | Identifier | Element idDiagnosticReport.identifier:Set-IDShort description Set-ID Alternate namesReportID, Filler ID, Placer ID DefinitionBefundnummer oder Eingangsnummer des Befundes 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. Usually assigned by the Information System of the diagnostic service provider (filler id). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
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| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/identifiers/patientMappings
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| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| basedOn | S C | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionVerweis auf den zugehörigen Untersuchungsauftrag This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. 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. Reference(MII_PR_Patho_Service_Request) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | S Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Status DefinitionStatus des Befundes Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Note that FHIR strings SHALL NOT exceed 1MB in size The status of the diagnostic report. DiagnosticReportStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Kategorie Alternate namesDepartment, Sub-department, Service, Discipline DefinitionKategorisierung des Befundes 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. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionCode des Pathologie-Befundes Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Pathologie-Befund Code DefinitionSpezifischer Code für Pathologie-Befunde Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
60568-3Mappings
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description Patient Alternate namesPatient DefinitionVerweis auf den Patienten SHALL know the subject context. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| encounter | S Σ C | 0..1 | Reference(Encounter) | Element idDiagnosticReport.encounterShort description Fall Alternate namesContext DefinitionVerweis auf den Fall Links the request to the Encounter context. 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). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| effective[x] | S Σ | 0..1 | Element idDiagnosticReport.effective[x]Short description Dokumentationsdatum Alternate namesObservation time, Effective Time, Occurrence DefinitionZeitpunkt der Befunderstellung Need to know where in the patient history to file/present this report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| performer | S Σ C | 1..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | Element idDiagnosticReport.performerShort description Autor Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionErsteller des Befundes 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. 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. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| resultsInterpreter | Σ C | 0..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. 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. Might not be the same entity that takes responsibility for the clinical report. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| specimen | S C | 1..* | Reference(Specimen) | Element idDiagnosticReport.specimenShort description Probe DefinitionVerweis auf die untersuchte Probe Need to be able to report information about the collected specimens on which the report is based. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| result | S C | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Ergebnis Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReferenz auf Beobachtungsberichtsabschnitte mit Einzelbeobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| intraoperative-observations | S C | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf intraoperative Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| macroscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf makroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| microscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf mikroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| additional-observations | S C | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf zusätzliche Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| diagnostic-conclusion | S C | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf die diagnostische Schlussfolgerung Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| imagingStudy | S C | 0..* | Reference(ImagingStudy) | Element idDiagnosticReport.imagingStudyShort description Bildinformationen DefinitionVerweis auf Bildinformationen 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionVerweis auf angehängte Bilder Many diagnostic services include images in the report as part of their service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA 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. The provider of the report should make a comment about each image included in the report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| link | S Σ C | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(MII_PR_Patho_Attached_Image) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| conclusionCode | S | 0..* | CodeableConcept | Element idDiagnosticReport.conclusionCodeShort description Schlussfolgerungscode DefinitionKodierung für abschließende diagnostische Schlussfolgerung Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| presentedForm | S C | 0..* | Attachment | Element idDiagnosticReport.presentedFormShort description Menschenlesbare Form DefinitionPDF-Dokument Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe 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. 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.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies where the resource comes from DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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. canonical(StructureDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags applied to this resource DefinitionTags 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. 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. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Verwandter Bericht Alternate namesextensions, user content DefinitionVerweis auf Vorbefunde Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. 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. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Set-ID | S Σ | 1..1 | Identifier | Element idDiagnosticReport.identifier:Set-IDShort description Set-ID Alternate namesReportID, Filler ID, Placer ID DefinitionBefundnummer oder Eingangsnummer des Befundes 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. Usually assigned by the Information System of the diagnostic service provider (filler id). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
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| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/identifiers/patientMappings
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| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| basedOn | S C | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionVerweis auf den zugehörigen Untersuchungsauftrag This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. 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. Reference(MII_PR_Patho_Service_Request) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | S Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Status DefinitionStatus des Befundes Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Note that FHIR strings SHALL NOT exceed 1MB in size The status of the diagnostic report. DiagnosticReportStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Kategorie Alternate namesDepartment, Sub-department, Service, Discipline DefinitionKategorisierung des Befundes 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. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionCode des Pathologie-Befundes Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Pathologie-Befund Code DefinitionSpezifischer Code für Pathologie-Befunde Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
http://loinc.orgMappings
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| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
60568-3Mappings
| ||
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description Patient Alternate namesPatient DefinitionVerweis auf den Patienten SHALL know the subject context. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| encounter | S Σ C | 0..1 | Reference(Encounter) | Element idDiagnosticReport.encounterShort description Fall Alternate namesContext DefinitionVerweis auf den Fall Links the request to the Encounter context. 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). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| effective[x] | S Σ | 0..1 | Element idDiagnosticReport.effective[x]Short description Dokumentationsdatum Alternate namesObservation time, Effective Time, Occurrence DefinitionZeitpunkt der Befunderstellung Need to know where in the patient history to file/present this report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| performer | S Σ C | 1..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | Element idDiagnosticReport.performerShort description Autor Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionErsteller des Befundes 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. 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. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| resultsInterpreter | Σ C | 0..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. 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. Might not be the same entity that takes responsibility for the clinical report. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| specimen | S C | 1..* | Reference(Specimen) | Element idDiagnosticReport.specimenShort description Probe DefinitionVerweis auf die untersuchte Probe Need to be able to report information about the collected specimens on which the report is based. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| result | S C | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Ergebnis Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReferenz auf Beobachtungsberichtsabschnitte mit Einzelbeobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| intraoperative-observations | S C | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf intraoperative Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| macroscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf makroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| microscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf mikroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| additional-observations | S C | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf zusätzliche Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| diagnostic-conclusion | S C | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf die diagnostische Schlussfolgerung Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| imagingStudy | S C | 0..* | Reference(ImagingStudy) | Element idDiagnosticReport.imagingStudyShort description Bildinformationen DefinitionVerweis auf Bildinformationen 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionVerweis auf angehängte Bilder Many diagnostic services include images in the report as part of their service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA 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. The provider of the report should make a comment about each image included in the report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| link | S Σ C | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(MII_PR_Patho_Attached_Image) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| conclusionCode | S | 0..* | CodeableConcept | Element idDiagnosticReport.conclusionCodeShort description Schlussfolgerungscode DefinitionKodierung für abschließende diagnostische Schlussfolgerung Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| presentedForm | S C | 0..* | Attachment | Element idDiagnosticReport.presentedFormShort description Menschenlesbare Form DefinitionPDF-Dokument Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| MII_PR_Patho_Report (DiagnosticReport) | C | DiagnosticReport | There are no (further) constraints on this element Element idDiagnosticReportShort description A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Alternate namesReport, Test, Result, Results, Labs, Laboratory DefinitionThe 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. 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.
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| id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDiagnosticReport.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.meta.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.meta.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionId | Σ | 0..1 | id | There are no (further) constraints on this element Element idDiagnosticReport.meta.versionIdShort description Version specific identifier DefinitionThe version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| lastUpdated | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.meta.lastUpdatedShort description When the resource version last changed DefinitionWhen the resource last changed - e.g. when the version changed. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| source | Σ | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.meta.sourceShort description Identifies where the resource comes from DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| profile | S Σ | 0..* | canonical(StructureDefinition) | There are no (further) constraints on this element Element idDiagnosticReport.meta.profileShort description Profiles this resource claims to conform to DefinitionA list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. 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. canonical(StructureDefinition) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| security | Σ | 0..* | CodingBinding | There are no (further) constraints on this element Element idDiagnosticReport.meta.securityShort description Security Labels applied to this resource DefinitionSecurity labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| tag | Σ | 0..* | Coding | There are no (further) constraints on this element Element idDiagnosticReport.meta.tagShort description Tags applied to this resource DefinitionTags 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. 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. Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | S | 0..1 | Narrative | There are no (further) constraints on this element Element idDiagnosticReport.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDiagnosticReport.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
| |||
| extension | C | 0..* | Extension | Element idDiagnosticReport.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| related-report | S C | 0..* | Extension(RelatedArtifact) | Element idDiagnosticReport.extension:related-reportShort description Verwandter Bericht Alternate namesextensions, user content DefinitionVerweis auf Vorbefunde Note that in contrast this extension, the supportingInfo extension references other resources from the patient record that were used in creating the resource. http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| identifier | S Σ | 1..* | Identifier | Element idDiagnosticReport.identifierShort description Business identifier for report Alternate namesReportID, Filler ID, Placer ID DefinitionIdentifiers assigned to this report by the performer or other systems. 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. Usually assigned by the Information System of the diagnostic service provider (filler id). Unordered, Open, by $this.type(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| Set-ID | S Σ | 1..1 | Identifier | Element idDiagnosticReport.identifier:Set-IDShort description Set-ID Alternate namesReportID, Filler ID, Placer ID DefinitionBefundnummer oder Eingangsnummer des Befundes 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. Usually assigned by the Information System of the diagnostic service provider (filler id). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| type | S Σ | 1..1 | CodeableConceptBindingPattern | Element idDiagnosticReport.identifier:Set-ID.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v2-0203",
"code": "ACSN",
"display": "Accession ID"
}
]
}Mappings
| ||
| system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/identifiers/patientMappings
| ||
| value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
| ||
| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDiagnosticReport.identifier:Set-ID.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| basedOn | S C | 1..* | Reference(MII_PR_Patho_Service_Request) | Element idDiagnosticReport.basedOnShort description Reference to respective MII_PR_Patho_Service_Request Alternate namesRequest DefinitionVerweis auf den zugehörigen Untersuchungsauftrag This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon. 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. Reference(MII_PR_Patho_Service_Request) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| status | S Σ ?! | 1..1 | codeBinding | Element idDiagnosticReport.statusShort description Status DefinitionStatus des Befundes Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports. Note that FHIR strings SHALL NOT exceed 1MB in size The status of the diagnostic report. DiagnosticReportStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| category | S Σ | 0..* | CodeableConceptBinding | Element idDiagnosticReport.categoryShort description Kategorie Alternate namesDepartment, Sub-department, Service, Discipline DefinitionKategorisierung des Befundes 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. Codes for diagnostic service sections. MII_VS_Patho_Report_Category_HL7 (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| code | S Σ | 1..1 | CodeableConceptBinding | Element idDiagnosticReport.codeShort description Pathology report code Alternate namesType DefinitionCode des Pathologie-Befundes Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Codes that describe Diagnostic Reports. LOINCDiagnosticReportCodes (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| coding | Σ | 1..* | Coding | Element idDiagnosticReport.code.codingShort description Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| pathology-report | S Σ | 1..1 | CodingPattern | Element idDiagnosticReport.code.coding:pathology-reportShort description Pathologie-Befund Code DefinitionSpezifischer Code für Pathologie-Befunde Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
{
"system": "http://loinc.org",
"code": "60568-3"
}Mappings
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| system | S Σ | 1..1 | uriPattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.systemShort description Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
http://loinc.orgMappings
| ||
| version | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.versionShort description Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| code | S Σ | 1..1 | codePattern | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.codeShort description Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
60568-3Mappings
| ||
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.displayShort description Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idDiagnosticReport.code.coding:pathology-report.userSelectedShort description If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| text | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.code.textShort description Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| subject | S Σ C | 1..1 | Reference(Patient) | Element idDiagnosticReport.subjectShort description Patient Alternate namesPatient DefinitionVerweis auf den Patienten SHALL know the subject context. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| encounter | S Σ C | 0..1 | Reference(Encounter) | Element idDiagnosticReport.encounterShort description Fall Alternate namesContext DefinitionVerweis auf den Fall Links the request to the Encounter context. 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). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| effective[x] | S Σ | 0..1 | Element idDiagnosticReport.effective[x]Short description Dokumentationsdatum Alternate namesObservation time, Effective Time, Occurrence DefinitionZeitpunkt der Befunderstellung Need to know where in the patient history to file/present this report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| |||
| effectiveDateTime | dateTime | Data type | ||||
| issued | Σ | 0..1 | instant | There are no (further) constraints on this element Element idDiagnosticReport.issuedShort description DateTime this version was made Alternate namesDate published, Date Issued, Date Verified DefinitionThe date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. Clinicians need to be able to check the date that the report was released. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| performer | S Σ C | 1..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | Element idDiagnosticReport.performerShort description Autor Alternate namesLaboratory, Service, Practitioner, Department, Company, Authorized by, Director DefinitionErsteller des Befundes 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. 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. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| resultsInterpreter | Σ C | 0..* | Reference(CareTeam | Organization | Practitioner | PractitionerRole) | There are no (further) constraints on this element Element idDiagnosticReport.resultsInterpreterShort description Primary result interpreter Alternate namesAnalyzed by, Reported by DefinitionThe practitioner or organization that is responsible for the report's conclusions and interpretations. 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. Might not be the same entity that takes responsibility for the clinical report. Reference(CareTeam | Organization | Practitioner | PractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| specimen | S C | 1..* | Reference(Specimen) | Element idDiagnosticReport.specimenShort description Probe DefinitionVerweis auf die untersuchte Probe Need to be able to report information about the collected specimens on which the report is based. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| result | S C | 1..* | Reference(Observation) | Element idDiagnosticReport.resultShort description Ergebnis Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionReferenz auf Beobachtungsberichtsabschnitte mit Einzelbeobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Ordered, Closed, by resolve().code(Value) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| intraoperative-observations | S C | 0..1 | Reference(MII_PR_Patho_Intraoperative_Grouper) | Element idDiagnosticReport.result:intraoperative-observationsShort description Reference to intraoperative Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf intraoperative Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Intraoperative_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
| |||
| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
| ||
| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:intraoperative-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| macroscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Macroscopic_Grouper) | Element idDiagnosticReport.result:macroscopic-observationsShort description Reference to macroscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf makroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Macroscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:macroscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| microscopic-observations | S C | 0..1 | Reference(MII_PR_Patho_Microscopic_Grouper) | Element idDiagnosticReport.result:microscopic-observationsShort description Reference to microscopic Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf mikroskopische Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Microscopic_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:microscopic-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| additional-observations | S C | 0..1 | Reference(MII_PR_Patho_Additional_Specified_Grouper) | Element idDiagnosticReport.result:additional-observationsShort description Reference to any additional Observation grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf zusätzliche Beobachtungen Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Additional_Specified_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:additional-observations.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| diagnostic-conclusion | S C | 1..1 | Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) | Element idDiagnosticReport.result:diagnostic-conclusionShort description Reference to the 'Diagnostic Conclusion' grouper(s) Alternate namesData, Atomic Value, Result, Atomic result, Data, Test, Analyte, Battery, Organizer DefinitionVerweis auf die diagnostische Schlussfolgerung Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful. Observations can contain observations. Reference(MII_PR_Patho_Diagnostic_Conclusion_Grouper) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| reference | S Σ C | 1..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.referenceShort description Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server. The cardinality or value of this element may be affected by these constraints: ele-1, ref-1 Constraints
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| type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.typeShort description Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.identifierShort description Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any). The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.result:diagnostic-conclusion.displayShort description Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| imagingStudy | S C | 0..* | Reference(ImagingStudy) | Element idDiagnosticReport.imagingStudyShort description Bildinformationen DefinitionVerweis auf Bildinformationen 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| media | S Σ | 0..* | BackboneElement | Element idDiagnosticReport.mediaShort description Reference to single attached images Alternate namesDICOM, Slides, Scans DefinitionVerweis auf angehängte Bilder Many diagnostic services include images in the report as part of their service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDiagnosticReport.media.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| comment | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.media.commentShort description Comment about the image (e.g. explanation) DefinitionA 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. The provider of the report should make a comment about each image included in the report. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| link | S Σ C | 1..1 | Reference(MII_PR_Patho_Attached_Image) | Element idDiagnosticReport.media.linkShort description Reference to the image source DefinitionReference to the image source. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(MII_PR_Patho_Attached_Image) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| conclusion | 0..1 | string | There are no (further) constraints on this element Element idDiagnosticReport.conclusionShort description Clinical conclusion (interpretation) of test results Alternate namesReport DefinitionConcise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. Need to be able to provide a conclusion that is not lost among the basic result data. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| |||
| conclusionCode | S | 0..* | CodeableConcept | Element idDiagnosticReport.conclusionCodeShort description Schlussfolgerungscode DefinitionKodierung für abschließende diagnostische Schlussfolgerung Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. Diagnosis codes provided as adjuncts to the report. SNOMEDCTClinicalFindings (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
| ||
| presentedForm | S C | 0..* | Attachment | Element idDiagnosticReport.presentedFormShort description Menschenlesbare Form DefinitionPDF-Dokument Gives laboratory the ability to provide its own fully formatted report for clinical fidelity. "application/pdf" is recommended as the most reliable and interoperable in this context. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
|
In untenstehender Tabelle sind Elemente mit * markiert, die im Profil MII PR Patho Composition dupliziert werden.
Liste aller Must-Support Datenelemente
| FHIR-Element | Erklärung |
|---|---|
| DiagnosticReport.id | Must-support, jedoch optional |
| DiagnosticReport.meta | Must-support, jedoch optional |
| DiagnosticReport.text | Nicht empfohlenes optionales Narrativ, kompiliert aus den Texten der Grouper-Observations u./ o. der Observations (siehe Composition.text und Composition.section.text) |
| DiagnosticReport.extension:related-report | Verweis auf Vorbefund(e), die mit dem aktuellen Befund in sachlichem Zusammenhang stehen |
| DiagnosticReport.identifier | Befundnummer (Eingangsnummer, Fallnummer, Filler order number, Accession number) |
| *DiagnosticReport.basedOn | Bezug zum initialen ServiceRequest, muss stets gegeben sein |
| DiagnosticReport.status | Keine Vorgaben, vorläufige Befunde sind erlaubt |
| DiagnosticReport.category | Extensible Binding auf ValueSet MII VS Patho Report Category HL7 |
| DiagnosticReport.code | LOINC 60568-3 “Pathology Synoptic Report” |
| *DiagnosticReport.subject | Patient (erbt von Modul Person der MII https://www.medizininformatik-initiative.de/fhir/core/modul-person/StructureDefinition/Patient) |
| DiagnosticReport.encounter | Must-support, jedoch optional |
| *DiagnosticReport.effective[x] | Zeitpunkt der Probenentnahme (Zeitpunkt zu dem die gemessene Eigenschaft im Probenmaterial (e.g. Analytkonzentration)mutmaßlich der Eigenschaft im Patienten entsprach). Falls nicht dokumentiert, Laboreingangszeitpunkt als am nächsten liegender Zeitpunkt. Muss identisch sein zu Observation.effective[x].extension: KlinischerBezugszeitpunkt. Die Information wird sowohl im DiagnosticReport als auch in der Observation gespeichert um anschließend Datenauswertungen zu erleichtern. |
| *DiagnosticReport.issued | Zeitpunkt der Freigabe des Befundes |
| *DiagnosticReport.performer | Referenz zur Einrichtung (custodian), die den Report verantwortet. |
| DiagnosticReport.specimen | Referenzen zu allen Proben (Präparat vom Patienten, Proben im Pathologielabor) Zukünftige Spezifikationen weiterer Kerndatensatzmodule können diesbezüglich Vorgaben ausgestalten. |
| DiagnosticReport.result | Der DiagnosticReport sollte mind. ein Ergebnis in Form einer Grouper-Observation DiagnosticConclusion (22637-3 (Pathology report diagnosis)) enthalten. |
| DiagnosticReport.imagingStudy | Eingebundene Bilder |
| DiagnosticReport.media | Eingebundene Bilder |
| DiagnosticReport.conclusion | Textuelle Beschreibung der abschließenden ärztlichen Bewertung des Befundes |
| DiagnosticReport.conclusionCode | Kodierte abschließende Bewertung(en) |
| DiagnosticReport.presentedForm | PDF des Pathologiebefundberichts |
Mapping zum Logical Model
| FHIR-Element | Logisches Datenmodell |
|---|---|
| DiagnosticReport.id | Befundbericht.id |
| DiagnosticReport.identifier | Befundbericht.Identifikator |
| DiagnosticReport.basedOn | Untersuchungsauftrag |
| DiagnosticReport.status | Befundbericht.Status |
| DiagnosticReport.category | Befundbericht.Kategorie |
| DiagnosticReport.code | Befundbericht.Typ |
| DiagnosticReport.subject | Patient |
| DiagnosticReport.encounter | Referenz zum Modul Fall |
| DiagnosticReport.effective | Befundbericht.Datum |
| DiagnosticReport.issued | Befundbericht.Datum |
| DiagnosticReport.performer | Practitioner/Organization |
| DiagnosticReport.specimen | Probe |
| DiagnosticReport.result | Beobachtungsberichtabschnitt und Generische Pathologisch-anatomische Einzelbeobachtung |
| DiagnosticReport.media | Generische Pathologisch-anatomische Einzelbeobachtung.EingebettetesBild, Generische Pathologisch-anatomische Einzelbeobachtung.ROI |
| DiagnosticReport.conclusion | Befundbericht.Bewertung |
| DiagnosticReport.conclusionCode | Befundbericht.Kodierung |
| DiagnosticReport.presentedForm | Befundbericht.PDF |
Suchparameter
Folgende Suchparameter sind für das Modul Pathologie-Befund relevant, auch in Kombination:
Der Suchparameter
_idMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?_id=103270Anwendungshinweise: Weitere Informationen zur Suche nach
_idfinden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".Der Suchparameter
_lastUpdatedMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?_lastUpdated=2021-12-08Anwendungshinweise: Weitere Informationen zur Suche nach
_lastUpdatedfinden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".Der Suchparameter
_profileMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-reportAnwendungshinweise: Weitere Informationen zur Suche nach
_profilefinden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".Der Suchparameter
based-onMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?based-on=ServiceRequest/mii-exa-patho-requestAnwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.basedOnfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
categoryMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?category=CPGET [base]/DiagnosticReport?category=http://terminology.hl7.org/CodeSystem/v2-0074|CPAnwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.categoryfinden sich in der FHIR-Basisspezifikation - Abschnitt "token".Der Suchparameter
codeMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?code=http://loinc.org|60568-3GET [base]/DiagnosticReport?code=60568-3Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.codefinden sich in der FHIR-Basisspezifikation - Abschnitt "token".Der Suchparameter
conclusionMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?conclusion=http://snomed.info/sct|399490008GET [base]/DiagnosticReport?conclusion=399490008Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.conclusionCodefinden sich in der FHIR-Basisspezifikation - Abschnitt "token".Der Suchparameter
dateMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?date=2021-06-01Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.effectivefinden sich in der FHIR-Basisspezifikation - Abschnitt "date".Der Suchparameter
encounterMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?encounter=Encounter/234980Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.encounterfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
identifierMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?identifier=https://pathologie.klinikum-karlsruhe.de/fhir/fn/befundbericht|E21.12345GET [base]/DiagnosticReport?identifier=E21.12345Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.identifierfinden sich in der FHIR-Basisspezifikation - Abschnitt "token".Der Suchparameter
issuedMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?issued=2022-01-01Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.issuedfinden sich in der FHIR-Basisspezifikation - Abschnitt "date".Der Suchparameter
mediaMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?media=Media/ex-mii-patho-attached-imageAnwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.media.linkfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
patientMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?patient=Patient/12345Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.subject.where(resolve() is Patient)finden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
performerMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?performer=Practitioner/2346545Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.performerfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
resultMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?result=Observation/ex-mii-patho-macro-grouper-bAnwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.resultfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
specimenMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?specimen=Specimen/987976Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.specimenfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
statusMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?status=finalAnwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.statusfinden sich in der FHIR-Basisspezifikation - Abschnitt "token".Der Suchparameter
subjectMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?subject=Patient/12345Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.subjectfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".Der Suchparameter
imaging-studyMUSS unterstützt werden:Beispiele:
GET [base]/DiagnosticReport?imaging-study=ImagingStudy/978698Anwendungshinweise: Weitere Informationen zur Suche nach
DiagnosticReport.imagingStudyfinden sich in der FHIR-Basisspezifikation - Abschnitt "reference".
Beispiele
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