MII IG Pathologie-Befund EN v2026

Context in the overall project / references from other modules

The module Pathologie-Befund maps pathology findings that are typically collected in a pathology facility in a hospital. These reports play a central role in some use cases of the MII:

Pathology reports from routine examinations are essential for diagnosing and monitoring therapy for most diseases

Pathology reports are an important base for many clinical studies

References within the MII

A pathology report is always assigned to the person from whom the specimen were taken and related to a Versorgungsstellenkontakt. The Versorgungsstellenkontakt is a pathology facility-specific (Abteilungs)kontakt, the so-called submission, which summarizes all examination orders for samples from a person that were taken in a temporal and specialist context. This Versorgungsstellenkontakt does not have to be identical to the examination order. If a sample from a case is kept in a biobank for further examination, this sample can be mapped with the profiles in the module Bioproben. The results from a pathology report can be integrated as individual elements in various other modules, e.g. for tumor documentation.

On the other hand, reports from other disciplines (e.g. from the modules Molekulargenetischer Befundbericht or Labor can be included in pathology reports in whole or in part and interpreted in the sense of a synoptic evaluation.

Furthermore, a relationship to the module Diagnose can exist. A diagnosis can be referenced by an examination order (e.g. as part of the clinical information/anamnesis). However, this can also refer to a finding itself if it is to serve as evidence, e.g. for staging the diagnosis made.

References outside the MII

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