Medizininformatik Initiative - Modul Molekulargenetischer Befundbericht

Anforderung - ServiceRequest

Beschreibung

Der Laborauftrag oder die Anfrage, die die Durchführung des genetischen Tests auslöst.

In der Anforderung können auch ein oder mehrere bekannte Symptome über das reasonReference Element als 'Phenotypic Features', die in GA4GH's Phenopackets IG profiliert sind, angegeben werden.

Name	Canonical
MII_PR_MolGen_AnforderungGenetischerTest	https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/anforderung-genetischer-test

Diff

ServiceRequest	I		ServiceRequest	Element Id ServiceRequest Short description A request for a service to be performed Alternate names diagnostic request, referral, referral request, transfer of care request Definition A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. Data Type ServiceRequest Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4:If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-6:A resource should have narrative for robust management text.`div`.exists() dom-5:If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` prr-1:orderDetail SHALL only be present if code is present `orderDetail.empty() or code.exists()` Mappings rim:Entity. Role, or Act workflow:Request v2:ORC rim:Act[moodCode<=INT] MII-KDS:mide-dataelement-1733
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element Id ServiceRequest.identifier Short description Identifiers assigned to this order Definition Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. Comments The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Request.identifier w5:FiveWs.identifier v2:ORC.2, ORC.3, RF1-6 / RF1-11, rim:.identifier quick:ClinicalStatement.identifier
instantiatesCanonical	Σ	0..*	canonical(ActivityDefinition \| PlanDefinition)	There are no (further) constraints on this element Element Id ServiceRequest.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. Data Type canonical(ActivityDefinition \| PlanDefinition) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.instantiatesCanonical v2:Varies by domain rim:.outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element Id ServiceRequest.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.instantiatesUri v2:Varies by domain rim:.outboundRelationship[typeCode=DEFN].target
basedOn	S Σ I	0..*	Reference(CarePlan \| ServiceRequest \| MedicationRequest)	Element Id ServiceRequest.basedOn Short description What request fulfills Alternate names fulfills Definition Plan/proposal/order fulfilled by this request. Comments 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. Data Type Reference(CarePlan \| ServiceRequest \| MedicationRequest) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.basedOn v2:ORC.8 (plus others) rim:.outboundRelationship[typeCode=FLFS].target MII-KDS:mide-dataelement-1742 MII-KDS:mide-dataelement-1743
replaces	Σ I	0..*	Reference(ServiceRequest)	There are no (further) constraints on this element Element Id ServiceRequest.replaces Short description What request replaces Alternate names supersedes, prior, renewed order Definition The request takes the place of the referenced completed or terminated request(s). Comments 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. Data Type Reference(ServiceRequest) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.replaces v2:Handled by message location of ORC (ORC.1=RO or RU) rim:.outboundRelationship[typeCode=RPLC].target
requisition	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id ServiceRequest.requisition Short description Composite Request ID Alternate names grouperId, groupIdentifier Definition A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Requirements Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Comments Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Request.groupIdentifier v2:ORC.4 rim:.inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.status Short description draft \| active \| on-hold \| revoked \| completed \| entered-in-error \| unknown Definition The status of the order. Comments The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. Data Type code Binding The status of a service order. RequestStatus (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.status w5:FiveWs.status v2:ORC.5,RF1-1 rim:.status quick:Action.currentStatus
intent	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.intent Short description proposal \| plan \| directive \| order \| original-order \| reflex-order \| filler-order \| instance-order \| option Definition Whether the request is a proposal, plan, an original order or a reflex order. Comments This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. Data Type code Binding The kind of service request. RequestIntent (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.intent w5:FiveWs.class v2:N/A rim:.moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)
category	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.category Short description Classification of service Definition A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Requirements Used for filtering what service request are retrieved and displayed. Comments There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Data Type CodeableConcept Binding Classification of the requested service. ServiceRequestCategoryCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.class v2:RF1-5 rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="INT"].code
priority	Σ	0..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.priority Short description routine \| urgent \| asap \| stat Definition Indicates how quickly the ServiceRequest should be addressed with respect to other requests. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Meaning When Missing If missing, this task should be performed with normal priority Data Type code Binding Identifies the level of importance to be assigned to actioning the request. RequestPriority (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.priority w5:FiveWs.grade v2:TQ1.9, RF1-2 rim:.priorityCode
doNotPerform	Σ ?!	0..1	boolean	There are no (further) constraints on this element Element Id ServiceRequest.doNotPerform Short description True if service/procedure should not be performed Definition Set this to true if the record is saying that the service/procedure should NOT be performed. Requirements Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. Comments In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation. Meaning When Missing If missing, the request is a positive request e.g. "do perform" Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.doNotPerform rim:.actionNegationInd
code	S Σ	0..1	CodeableConcept	Element Id ServiceRequest.code Short description What is being requested/ordered Alternate names service requested Definition A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. Comments Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Data Type CodeableConcept Binding Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.code w5:FiveWs.what[x] v2:PR1-3 / OBR-4 (varies by domain) rim:.code quick:Procedure.procedureCode MII-KDS:mide-dataelement-1761 MII-KDS:mide-dataelement-1704
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id ServiceRequest.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	0..1	string	Element Id ServiceRequest.code.text Short description Plain text representation of the concept Alternate names Anforderungstext Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText MII-KDS:mide-dataelement-1763
orderDetail	Σ I	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.orderDetail Short description Additional order information Alternate names detailed instructions Definition Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. Comments For information from the medical record intended to support the delivery of the requested services, use the `supportingInformation` element. Data Type CodeableConcept Binding Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:NTE rim:.code quick:Procedure.procedureCode
quantity[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.quantity[x] Short description Service amount Definition An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). Requirements When ordering a service the number of service items may need to be specified separately from the the service item. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:NTE rim:.quantity
quantityQuantity			Quantity	There are no (further) constraints on this element Data Type Quantity
quantityRatio			Ratio	There are no (further) constraints on this element Data Type Ratio
quantityRange			Range	There are no (further) constraints on this element Data Type Range
subject	S Σ I	1..1	MII-Reference(Patient \| Group)	Element Id ServiceRequest.subject Short description A reference from one resource to another Definition A reference from one resource to another. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type MII-Reference(Patient \| Group) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` mii-reference-1:Either reference.reference OR reference.identifier exists `($this.reference.exists() or ($this.identifier.value.exists() and $this.identifier.system.exists())) xor $this.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.subject w5:FiveWs.subject[x] v2:PID rim:.participation[typeCode=SBJ].role quick:ClinicalStatement.subject w5:FiveWs.subject
encounter	S Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element Id ServiceRequest.encounter Short description Encounter in which the request was created Alternate names context Definition An encounter that provides additional information about the healthcare context in which this request is made. Comments 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. Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.encounter w5:FiveWs.context v2:PV1 rim:.inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN] quick:ClinicalStatement.encounter
occurrence[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.occurrence[x] Short description When service should occur Alternate names schedule Definition The date/time at which the requested service should occur. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.occurrence[x] w5:FiveWs.planned v2:TQ1/TQ2, OBR-7/OBR-8 rim:.effectiveTime quick:Procedure.procedureSchedule
occurrenceDateTime			dateTime	There are no (further) constraints on this element Data Type dateTime
occurrencePeriod			Period	There are no (further) constraints on this element Data Type Period
occurrenceTiming			Timing	There are no (further) constraints on this element Data Type Timing
asNeeded[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.asNeeded[x] Short description Preconditions for service Definition If a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. Binding A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code="Assertion"].value quick:Proposal.prnReason.reason
asNeededBoolean			boolean	There are no (further) constraints on this element Data Type boolean
asNeededCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data Type CodeableConcept
authoredOn	S Σ	0..1	dateTime	Element Id ServiceRequest.authoredOn Short description Date request signed Alternate names orderedOn, Datum der Anforderung Definition When the request transitioned to being actionable. Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.authoredOn w5:FiveWs.recorded v2:ORC.9, RF1-7 / RF1-9 rim:.participation[typeCode=AUT].time quick:Proposal.proposedAtTime MII-KDS:mide-dataelement-1766
requester	S Σ I	0..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	Element Id ServiceRequest.requester Short description Who/what is requesting service Alternate names author, orderer, Anforderer Definition The individual who initiated the request and has responsibility for its activation. Comments This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource. Data Type Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.requester w5:FiveWs.author v2:ORC.12, PRT rim:.participation[typeCode=AUT].role quick:ClinicalStatement.statementAuthor MII-KDS:mide-dataelement-1746
performerType	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.performerType Short description Performer role Alternate names specialty Definition Desired type of performer for doing the requested service. Comments This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Data Type CodeableConcept Binding Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.performerType w5:FiveWs.actor v2:PRT, RF!-3 rim:.participation[typeCode=PRF].role[scoper.determinerCode=KIND].code
performer	Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson)	There are no (further) constraints on this element Element Id ServiceRequest.performer Short description Requested performer Alternate names request recipient Definition The desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. Comments If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Data Type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.performer w5:FiveWs.actor v2:PRT, Practitioner: PRD-2/PRD-7 where PRD-3 = RT; Organization: PRD-10 where PRD-3 = RT rim:.participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]
locationCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.locationCode Short description Requested location Definition The preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Comments 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. Data Type CodeableConcept Binding A location type where services are delivered. ServiceDeliveryLocationRoleType (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.actor rim:.participation[typeCode=LOC].role[scoper.determinerCode=KIND].code
locationReference	Σ I	0..*	Reference(Location)	There are no (further) constraints on this element Element Id ServiceRequest.locationReference Short description Requested location Definition A reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. Comments 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. Data Type Reference(Location) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.actor rim:.participation[typeCode=LOC].role[scoper.determinerCode=INSTANCE]
reasonCode	S Σ	0..*	CodeableConcept	Element Id ServiceRequest.reasonCode Short description Explanation/Justification for procedure or service Alternate names Indikation Definition An explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use `CodeableConcept.text` element if the data is free (uncoded) text as shown in the CT Scan example. Data Type CodeableConcept Binding Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.reasonCode w5:FiveWs.why[x] v2:ORC.16, RF1-10 rim:.reasonCode MII-KDS:mide-dataelement-1736
reasonReference	S Σ I	0..*	Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference)	Element Id ServiceRequest.reasonReference Short description Explanation/Justification for service or service Definition Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in `DiagnosticReport.conclusion` and/or `DiagnosticReport.conclusionCode`. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in `ServiceRequest.reasonCode` if the data is free (uncoded) text as shown in the CT Scan example. Data Type Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.reasonReference w5:FiveWs.why[x] v2:ORC.16 rim:.outboundRelationship[typeCode=RSON].target MII-KDS:mide-dataelement-1744 MII-KDS:mide-dataelement-1745
insurance	I	0..*	Reference(Coverage \| ClaimResponse)	There are no (further) constraints on this element Element Id ServiceRequest.insurance Short description Associated insurance coverage Definition Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. Comments 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. Data Type Reference(Coverage \| ClaimResponse) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.insurance v2:IN1/IN2 rim:.outboundRelationship[typeCode=COVBY].target
supportingInfo	S I	0..*	Reference(Resource)	Element Id ServiceRequest.supportingInfo Short description Additional clinical information Alternate names Ask at order entry question, AOE Definition Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. Comments To represent information about how the services are to be delivered use the `instructions` element. Data Type Reference(Resource) Sliced: Unordered, Open, by resolve()(Profile) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.supportingInfo v2:Accompanying segments rim:.outboundRelationship[typeCode=PERT].target MII-KDS:mide-dataelement-1738 MII-KDS:mide-dataelement-1739 MII-KDS:mide-dataelement-1740 MII-KDS:mide-dataelement-1741
familienanamnese	I	0..*	Reference(MII PR MolGen Familienanamnese)	Element Id ServiceRequest.supportingInfo:familienanamnese Short description Additional clinical information Alternate names Ask at order entry question, AOE Definition Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. Comments To represent information about how the services are to be delivered use the `instructions` element. Data Type Reference(MII PR MolGen Familienanamnese) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.supportingInfo v2:Accompanying segments rim:.outboundRelationship[typeCode=PERT].target
specimen	Σ I	0..*	Reference(Specimen)	There are no (further) constraints on this element Element Id ServiceRequest.specimen Short description Procedure Samples Definition One or more specimens that the laboratory procedure will use. Comments Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest. Data Type Reference(Specimen) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2:SPM rim:.participation[typeCode=SPC].role
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.bodySite Short description Location on Body Alternate names location Definition Anatomic location where the procedure should be performed. This is the target site. Requirements Knowing where the procedure is performed is important for tracking if multiple sites are possible. Comments Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Data Type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:SPM rim:targetSiteCode quick:Procedure.targetBodySite
note	S	0..*	Annotation	Element Id ServiceRequest.note Short description Comments Alternate names Anforderungstext Definition Any other notes and comments made about the service request. For example, internal billing notes. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Data Type Annotation Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Act workflow:Request.note v2:NTE rim:.inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST] quick:ClinicalStatement.additionalText MII-KDS:mide-dataelement-1763
patientInstruction	Σ	0..1	string	There are no (further) constraints on this element Element Id ServiceRequest.patientInstruction Short description Patient or consumer-oriented instructions Definition Instructions in terms that are understood by the patient or consumer. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:NTE rim:.text
relevantHistory	I	0..*	Reference(Provenance)	There are no (further) constraints on this element Element Id ServiceRequest.relevantHistory Short description Request provenance Definition Key events in the history of the request. Comments This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject. Data Type Reference(Provenance) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.relevantHistory v2:N/A rim:.inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]

Snapshot

ServiceRequest	I		ServiceRequest	Element Id ServiceRequest Short description A request for a service to be performed Alternate names diagnostic request, referral, referral request, transfer of care request Definition A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. Data Type ServiceRequest Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4:If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()` dom-3:If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource `contained.where((('#'+id in (%resource.descendants().reference \| %resource.descendants().as(canonical) \| %resource.descendants().as(uri) \| %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()` dom-6:A resource should have narrative for robust management text.`div`.exists() dom-5:If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` prr-1:orderDetail SHALL only be present if code is present `orderDetail.empty() or code.exists()` Mappings rim:Entity. Role, or Act workflow:Request v2:ORC rim:Act[moodCode<=INT] MII-KDS:mide-dataelement-1733
identifier	Σ	0..*	Identifier	There are no (further) constraints on this element Element Id ServiceRequest.identifier Short description Identifiers assigned to this order Definition Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. Comments The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Request.identifier w5:FiveWs.identifier v2:ORC.2, ORC.3, RF1-6 / RF1-11, rim:.identifier quick:ClinicalStatement.identifier
instantiatesCanonical	Σ	0..*	canonical(ActivityDefinition \| PlanDefinition)	There are no (further) constraints on this element Element Id ServiceRequest.instantiatesCanonical Short description Instantiates FHIR protocol or definition Definition The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. Data Type canonical(ActivityDefinition \| PlanDefinition) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.instantiatesCanonical v2:Varies by domain rim:.outboundRelationship[typeCode=DEFN].target
instantiatesUri	Σ	0..*	uri	There are no (further) constraints on this element Element Id ServiceRequest.instantiatesUri Short description Instantiates external protocol or definition Definition The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. Comments This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.instantiatesUri v2:Varies by domain rim:.outboundRelationship[typeCode=DEFN].target
basedOn	S Σ I	0..*	Reference(CarePlan \| ServiceRequest \| MedicationRequest)	Element Id ServiceRequest.basedOn Short description What request fulfills Alternate names fulfills Definition Plan/proposal/order fulfilled by this request. Comments 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. Data Type Reference(CarePlan \| ServiceRequest \| MedicationRequest) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.basedOn v2:ORC.8 (plus others) rim:.outboundRelationship[typeCode=FLFS].target MII-KDS:mide-dataelement-1742 MII-KDS:mide-dataelement-1743
replaces	Σ I	0..*	Reference(ServiceRequest)	There are no (further) constraints on this element Element Id ServiceRequest.replaces Short description What request replaces Alternate names supersedes, prior, renewed order Definition The request takes the place of the referenced completed or terminated request(s). Comments 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. Data Type Reference(ServiceRequest) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.replaces v2:Handled by message location of ORC (ORC.1=RO or RU) rim:.outboundRelationship[typeCode=RPLC].target
requisition	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id ServiceRequest.requisition Short description Composite Request ID Alternate names grouperId, groupIdentifier Definition A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. Requirements Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. Comments Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier workflow:Request.groupIdentifier v2:ORC.4 rim:.inboundRelationship(typeCode=COMP].source[moodCode=INT].identifier
status	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.status Short description draft \| active \| on-hold \| revoked \| completed \| entered-in-error \| unknown Definition The status of the order. Comments The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. Data Type code Binding The status of a service order. RequestStatus (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.status w5:FiveWs.status v2:ORC.5,RF1-1 rim:.status quick:Action.currentStatus
intent	Σ ?!	1..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.intent Short description proposal \| plan \| directive \| order \| original-order \| reflex-order \| filler-order \| instance-order \| option Definition Whether the request is a proposal, plan, an original order or a reflex order. Comments This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. Data Type code Binding The kind of service request. RequestIntent (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.intent w5:FiveWs.class v2:N/A rim:.moodCode (nuances beyond PRP/PLAN/RQO would need to be elsewhere)
category	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.category Short description Classification of service Definition A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). Requirements Used for filtering what service request are retrieved and displayed. Comments There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. Data Type CodeableConcept Binding Classification of the requested service. ServiceRequestCategoryCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.class v2:RF1-5 rim:.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="INT"].code
priority	Σ	0..1	codeBinding	There are no (further) constraints on this element Element Id ServiceRequest.priority Short description routine \| urgent \| asap \| stat Definition Indicates how quickly the ServiceRequest should be addressed with respect to other requests. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Meaning When Missing If missing, this task should be performed with normal priority Data Type code Binding Identifies the level of importance to be assigned to actioning the request. RequestPriority (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.priority w5:FiveWs.grade v2:TQ1.9, RF1-2 rim:.priorityCode
doNotPerform	Σ ?!	0..1	boolean	There are no (further) constraints on this element Element Id ServiceRequest.doNotPerform Short description True if service/procedure should not be performed Definition Set this to true if the record is saying that the service/procedure should NOT be performed. Requirements Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. Comments In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation. Meaning When Missing If missing, the request is a positive request e.g. "do perform" Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.doNotPerform rim:.actionNegationInd
code	S Σ	0..1	CodeableConcept	Element Id ServiceRequest.code Short description What is being requested/ordered Alternate names service requested Definition A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. Comments Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. Data Type CodeableConcept Binding Codes for tests or services that can be carried out by a designated individual, organization or healthcare service. For laboratory, LOINC is (preferred)[http://build.fhir.org/terminologies.html#preferred] and a valueset using LOINC Order codes is available [here](valueset-diagnostic-requests.html). ProcedureCodes(SNOMEDCT) (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.code w5:FiveWs.what[x] v2:PR1-3 / OBR-4 (varies by domain) rim:.code quick:Procedure.procedureCode MII-KDS:mide-dataelement-1761 MII-KDS:mide-dataelement-1704
coding	Σ	0..*	Coding	There are no (further) constraints on this element Element Id ServiceRequest.code.coding Short description Code defined by a terminology system Definition A reference to a code defined by a terminology system. Requirements Allows for alternative encodings within a code system, and translations to other code systems. Comments 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. Data Type Coding Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim:CV orim:fhir:Coding rdfs:subClassOf dt:CDCoding v2:CE.1-8, CE.10-22 rim:union(., ./translation) orim:fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
text	Σ	0..1	string	Element Id ServiceRequest.code.text Short description Plain text representation of the concept Alternate names Anforderungstext Definition A 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. Requirements 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. Comments Very often the text is the same as a displayName of one of the codings. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.9. But note many systems use CE.2 for this rim:./originalText[mediaType/code="text/plain"]/data orim:fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText MII-KDS:mide-dataelement-1763
orderDetail	Σ I	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.orderDetail Short description Additional order information Alternate names detailed instructions Definition Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. Comments For information from the medical record intended to support the delivery of the requested services, use the `supportingInformation` element. Data Type CodeableConcept Binding Codified order entry details which are based on order context. ServiceRequestOrderDetailsCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:NTE rim:.code quick:Procedure.procedureCode
quantity[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.quantity[x] Short description Service amount Definition An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). Requirements When ordering a service the number of service items may need to be specified separately from the the service item. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:NTE rim:.quantity
quantityQuantity			Quantity	There are no (further) constraints on this element Data Type Quantity
quantityRatio			Ratio	There are no (further) constraints on this element Data Type Ratio
quantityRange			Range	There are no (further) constraints on this element Data Type Range
subject	S Σ I	1..1	MII-Reference(Patient \| Group)	Element Id ServiceRequest.subject Short description A reference from one resource to another Definition A reference from one resource to another. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data Type MII-Reference(Patient \| Group) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` mii-reference-1:Either reference.reference OR reference.identifier exists `($this.reference.exists() or ($this.identifier.value.exists() and $this.identifier.system.exists())) xor $this.extension('http://hl7.org/fhir/StructureDefinition/data-absent-reason').exists()` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.subject w5:FiveWs.subject[x] v2:PID rim:.participation[typeCode=SBJ].role quick:ClinicalStatement.subject w5:FiveWs.subject
encounter	S Σ I	0..1	Reference(Encounter)	There are no (further) constraints on this element Element Id ServiceRequest.encounter Short description Encounter in which the request was created Alternate names context Definition An encounter that provides additional information about the healthcare context in which this request is made. Comments 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. Data Type Reference(Encounter) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.encounter w5:FiveWs.context v2:PV1 rim:.inboundRelationship(typeCode=COMP].source[classCode<=PCPR, moodCode=EVN] quick:ClinicalStatement.encounter
occurrence[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.occurrence[x] Short description When service should occur Alternate names schedule Definition The date/time at which the requested service should occur. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.occurrence[x] w5:FiveWs.planned v2:TQ1/TQ2, OBR-7/OBR-8 rim:.effectiveTime quick:Procedure.procedureSchedule
occurrenceDateTime			dateTime	There are no (further) constraints on this element Data Type dateTime
occurrencePeriod			Period	There are no (further) constraints on this element Data Type Period
occurrenceTiming			Timing	There are no (further) constraints on this element Data Type Timing
asNeeded[x]	Σ	0..1		There are no (further) constraints on this element Element Id ServiceRequest.asNeeded[x] Short description Preconditions for service Definition If a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. Binding A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc. SNOMEDCTMedicationAsNeededReasonCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:boolean: precondition.negationInd (inversed - so negationInd = true means asNeeded=false CodeableConcept: precondition.observationEventCriterion[code="Assertion"].value quick:Proposal.prnReason.reason
asNeededBoolean			boolean	There are no (further) constraints on this element Data Type boolean
asNeededCodeableConcept			CodeableConcept	There are no (further) constraints on this element Data Type CodeableConcept
authoredOn	S Σ	0..1	dateTime	Element Id ServiceRequest.authoredOn Short description Date request signed Alternate names orderedOn, Datum der Anforderung Definition When the request transitioned to being actionable. Data Type dateTime Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a workflow:Request.authoredOn w5:FiveWs.recorded v2:ORC.9, RF1-7 / RF1-9 rim:.participation[typeCode=AUT].time quick:Proposal.proposedAtTime MII-KDS:mide-dataelement-1766
requester	S Σ I	0..1	Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device)	Element Id ServiceRequest.requester Short description Who/what is requesting service Alternate names author, orderer, Anforderer Definition The individual who initiated the request and has responsibility for its activation. Comments This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource. Data Type Reference(Practitioner \| PractitionerRole \| Organization \| Patient \| RelatedPerson \| Device) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.requester w5:FiveWs.author v2:ORC.12, PRT rim:.participation[typeCode=AUT].role quick:ClinicalStatement.statementAuthor MII-KDS:mide-dataelement-1746
performerType	Σ	0..1	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.performerType Short description Performer role Alternate names specialty Definition Desired type of performer for doing the requested service. Comments This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. Data Type CodeableConcept Binding Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc. ParticipantRoles (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.performerType w5:FiveWs.actor v2:PRT, RF!-3 rim:.participation[typeCode=PRF].role[scoper.determinerCode=KIND].code
performer	Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson)	There are no (further) constraints on this element Element Id ServiceRequest.performer Short description Requested performer Alternate names request recipient Definition The desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. Comments If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). Data Type Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam \| HealthcareService \| Patient \| Device \| RelatedPerson) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.performer w5:FiveWs.actor v2:PRT, Practitioner: PRD-2/PRD-7 where PRD-3 = RT; Organization: PRD-10 where PRD-3 = RT rim:.participation[typeCode=PRF].role[scoper.determinerCode=INSTANCE]
locationCode	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.locationCode Short description Requested location Definition The preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. Comments 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. Data Type CodeableConcept Binding A location type where services are delivered. ServiceDeliveryLocationRoleType (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD w5:FiveWs.actor rim:.participation[typeCode=LOC].role[scoper.determinerCode=KIND].code
locationReference	Σ I	0..*	Reference(Location)	There are no (further) constraints on this element Element Id ServiceRequest.locationReference Short description Requested location Definition A reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. Comments 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. Data Type Reference(Location) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) w5:FiveWs.actor rim:.participation[typeCode=LOC].role[scoper.determinerCode=INSTANCE]
reasonCode	S Σ	0..*	CodeableConcept	Element Id ServiceRequest.reasonCode Short description Explanation/Justification for procedure or service Alternate names Indikation Definition An explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use `CodeableConcept.text` element if the data is free (uncoded) text as shown in the CT Scan example. Data Type CodeableConcept Binding Diagnosis or problem codes justifying the reason for requesting the service investigation. ProcedureReasonCodes (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD workflow:Request.reasonCode w5:FiveWs.why[x] v2:ORC.16, RF1-10 rim:.reasonCode MII-KDS:mide-dataelement-1736
reasonReference	S Σ I	0..*	Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference)	Element Id ServiceRequest.reasonReference Short description Explanation/Justification for service or service Definition Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in `supportingInfo`. Comments This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in `DiagnosticReport.conclusion` and/or `DiagnosticReport.conclusionCode`. When using a reference to DocumentReference, the target document should contain clear findings language providing the relevant reason for this service request. Use the CodeableConcept text element in `ServiceRequest.reasonCode` if the data is free (uncoded) text as shown in the CT Scan example. Data Type Reference(Condition \| Observation \| DiagnosticReport \| DocumentReference) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.reasonReference w5:FiveWs.why[x] v2:ORC.16 rim:.outboundRelationship[typeCode=RSON].target MII-KDS:mide-dataelement-1744 MII-KDS:mide-dataelement-1745
insurance	I	0..*	Reference(Coverage \| ClaimResponse)	There are no (further) constraints on this element Element Id ServiceRequest.insurance Short description Associated insurance coverage Definition Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. Comments 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. Data Type Reference(Coverage \| ClaimResponse) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.insurance v2:IN1/IN2 rim:.outboundRelationship[typeCode=COVBY].target
supportingInfo	S I	0..*	Reference(Resource)	Element Id ServiceRequest.supportingInfo Short description Additional clinical information Alternate names Ask at order entry question, AOE Definition Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. Comments To represent information about how the services are to be delivered use the `instructions` element. Data Type Reference(Resource) Sliced: Unordered, Open, by resolve()(Profile) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.supportingInfo v2:Accompanying segments rim:.outboundRelationship[typeCode=PERT].target MII-KDS:mide-dataelement-1738 MII-KDS:mide-dataelement-1739 MII-KDS:mide-dataelement-1740 MII-KDS:mide-dataelement-1741
familienanamnese	I	0..*	Reference(MII PR MolGen Familienanamnese)	Element Id ServiceRequest.supportingInfo:familienanamnese Short description Additional clinical information Alternate names Ask at order entry question, AOE Definition Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. Comments To represent information about how the services are to be delivered use the `instructions` element. Data Type Reference(MII PR MolGen Familienanamnese) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.supportingInfo v2:Accompanying segments rim:.outboundRelationship[typeCode=PERT].target
specimen	Σ I	0..*	Reference(Specimen)	There are no (further) constraints on this element Element Id ServiceRequest.specimen Short description Procedure Samples Definition One or more specimens that the laboratory procedure will use. Comments Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest. Data Type Reference(Specimen) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) v2:SPM rim:.participation[typeCode=SPC].role
bodySite	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element Id ServiceRequest.bodySite Short description Location on Body Alternate names location Definition Anatomic location where the procedure should be performed. This is the target site. Requirements Knowing where the procedure is performed is important for tracking if multiple sites are possible. Comments Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. Data Type CodeableConcept Binding Codes describing anatomical locations. May include laterality. SNOMEDCTBodyStructures (example) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE/CNE/CWE rim:CD orim:fhir:CodeableConcept rdfs:subClassOf dt:CD v2:SPM rim:targetSiteCode quick:Procedure.targetBodySite
note	S	0..*	Annotation	Element Id ServiceRequest.note Short description Comments Alternate names Anforderungstext Definition Any other notes and comments made about the service request. For example, internal billing notes. Comments For systems that do not have structured annotations, they can simply communicate a single annotation with no author or time. This element may need to be included in narrative because of the potential for modifying information. Annotations SHOULD NOT be used to communicate "modifying" information that could be computable. (This is a SHOULD because enforcing user behavior is nearly impossible). Data Type Annotation Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:N/A rim:Act workflow:Request.note v2:NTE rim:.inboundRelationship(typeCode=SUBJ].source[classCode=ANNGEN, moodCode=EVN].value[xsi:type=ST] quick:ClinicalStatement.additionalText MII-KDS:mide-dataelement-1763
patientInstruction	Σ	0..1	string	There are no (further) constraints on this element Element Id ServiceRequest.patientInstruction Short description Patient or consumer-oriented instructions Definition Instructions in terms that are understood by the patient or consumer. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:NTE rim:.text
relevantHistory	I	0..*	Reference(Provenance)	There are no (further) constraints on this element Element Id ServiceRequest.relevantHistory Short description Request provenance Definition Key events in the history of the request. Comments This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject. Data Type Reference(Provenance) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1:SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim:n/a rim:The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow:Request.relevantHistory v2:N/A rim:.inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]

FHIR-Element	Logischer Datensatz
ServiceRequest.reasonCode	Anforderung.Indikation.Indikation
ServiceRequest.supportingInfo	Anforderung.Indikation.Gesundheitszustand
ServiceRequest.supportingInfo	Anforderung.Indikation.Anlageträger
ServiceRequest.reasonReference	Anforderung.Indikation.Relevante Vorergebnisse
ServiceRequest.code	Anforderung.Zu testende Gene
ServiceRequest.code.text	Anforderung.Anforderungstext
ServiceRequest.authoredOn	Anforderung.Datum der Anforderung
ServiceRequest.requester	Anforderung.Anforderer
ServiceRequest.note	Anforderung.Anforderung.Anforderungstext
ServiceRequest.subject	Anforderung.Probeninformationen.Patient
ServiceRequest.supportingInfo	Anforderung.Indikation.Krankengeschichte Familie

Suchparameter

Folgende Suchparameter sind für das Modul Pathologie-Befund relevant, auch in Kombination:

Der Suchparameter _id MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?_id=1234

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

Beispiele:

GET [base]/ServiceRequest?_profile=https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/anforderung-genetischer-test

Anwendungshinweise: Weitere Informationen zur Suche nach "_profile" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "code" MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?code=http://snomed.info/sct|405825005

Anwendungshinweise: Weitere Informationen zur Suche nach "code" finden sich in der FHIR-Basisspezifikation - Abschnitt "token".
Der Suchparameter "based-on" MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?based-on=ServiceRequest/12345

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

Beispiele:

GET [base]/ServiceRequest?subject=Patient/example-mii-molgen-patient

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

Beispiele:

GET [base]/ServiceRequest?authored=2022-04-07

Anwendungshinweise: Weitere Informationen zur Suche nach "authored" finden sich in der FHIR-Basisspezifikation - Abschnitt "date".
Der Suchparameter "requestor" MUSS unterstützt werden:

Beispiele:

GET [base]/ServiceRequest?requestor=Practioner/example-mii-molgen-practitioner-physician

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

Beispiele:

GET [base]/ServiceRequest?reason-code=http://snomed.info/sct|447886005

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

Beispiele:

GET [base]/ServiceRequest?reason-reference=Condition/12345

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

Examples

Anforderung 1 - BRAF

{
    "resourceType": "ServiceRequest",
    "id": "mii-exa-molgen-anforderung-1",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/anforderung-genetischer-test"
        ]
    },
    "status": "active",
    "intent": "order",
    "category":  [
        {
            "coding":  [
                {
                    "code": "108252007",
                    "system": "http://snomed.info/sct",
                    "display": "Laboratory procedure (procedure)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "405825005",
                "system": "http://snomed.info/sct",
                "display": "Molecular genetic test (procedure)"
            },
            {
                "code": "53844-7",
                "system": "http://loinc.org",
                "display": "BRAF gene targeted mutation analysis in Blood or Tissue by Molecular genetics method"
            },
            {
                "code": "HGNC:1097",
                "system": "http://www.genenames.org/geneId",
                "display": "BRAF"
            }
        ],
        "text": "BRAF: Exon 15 (Codon 600)"
    },
    "subject": {
        "reference": "Patient/mii-exa-molgen-patient"
    },
    "authoredOn": "2022-04-07",
    "requester": {
        "reference": "Practitioner/mii-exa-molgen-practitioner-physician"
    },
    "reasonCode":  [
        {
            "coding":  [
                {
                    "code": "447886005",
                    "system": "http://snomed.info/sct",
                    "display": "Adenocarcinoma of anorectum (disorder)"
                }
            ]
        }
    ],
    "specimen":  [
        {
            "reference": "Specimen/mii-exa-molgen-specimen-1"
        }
    ],
    "supportingInfo":  [
        {
            "reference": "FamilyMemberHistory/mii-exa-molgen-family-member-history-1"
        }
    ]
}

Beispiel des in der Anforderung 1 referenzierten Specimens (Probe) basierend auf dem Profil des MII Moduls Biobank.

{
    "resourceType": "Specimen",
    "id": "mii-exa-molgen-specimen-1",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/StructureDefinition/SpecimenCore"
        ]
    },
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "128159001",
                "display": "Tissue specimen from colon (specimen)"
            }
        ]
    },
    "collection": {
        "collectedDateTime": "2022-03-24T12:44:00+01:00",
        "bodySite": {
            "coding":  [
                {
                    "code": "71854001",
                    "system": "http://snomed.info/sct",
                    "display": "Colon structure (body structure)"
                }
            ]
        }
    },
    "identifier":  [
        {
            "system": "https://biobank.uk-musterstadt.de/fhir/sid/proben",
            "value": "5432"
        }
    ],
    "status": "available",
    "subject": {
        "reference": "Patient/mii-exa-molgen-patient"
    }
}

Anforderung 2 - NIPBL

{
    "resourceType": "ServiceRequest",
    "id": "mii-exa-molgen-anforderung-2",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/anforderung-genetischer-test"
        ]
    },
    "identifier":  [
        {
            "system": "https://www.charite.de/fhir/auftragsnummern",
            "value": "gen_test_02"
        }
    ],
    "status": "active",
    "intent": "order",
    "category":  [
        {
            "coding":  [
                {
                    "code": "108252007",
                    "system": "http://snomed.info/sct",
                    "display": "Laboratory procedure (procedure)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "405825005",
                "system": "http://snomed.info/sct",
                "display": "Molecular genetic test (procedure)"
            },
            {
                "code": "40428-5",
                "system": "http://loinc.org",
                "display": "NIPBL gene targeted mutation analysis in Blood or Tissue by Molecular genetics method"
            },
            {
                "code": "HGNC:28862",
                "system": "http://www.genenames.org/geneId",
                "display": "NIPBL"
            }
        ],
        "text": "Molekulargenetische Diagnose eines Cornelia de Lange-Syndrom (MIM122470),autosomal dominanter Erbgang"
    },
    "subject": {
        "reference": "Patient/mii-exa-molgen-patient-2"
    },
    "authoredOn": "2022-03-16",
    "requester": {
        "reference": "Practitioner/mii-exa-molgen-practitioner-physician"
    },
    "specimen":  [
        {
            "reference": "Specimen/mii-exa-molgen-specimen-2"
        }
    ],
    "reasonCode":  [
        {
            "coding":  [
                {
                    "code": "395507008",
                    "system": "http://snomed.info/sct",
                    "display": "Premature infant (finding)"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "276610007",
                    "system": "http://snomed.info/sct",
                    "display": "Low birth weight infant (disorder)"
                },
                {
                    "code": "HP:0001518",
                    "system": "http://human-phenotype-ontology.org",
                    "display": "Small for gestational age"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "431265009",
                    "system": "http://snomed.info/sct",
                    "display": "Fetal microcephaly (disorder)"
                },
                {
                    "code": "HP:0000252",
                    "system": "http://human-phenotype-ontology.org",
                    "display": "Microcephaly"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "137511000119103",
                    "system": "http://snomed.info/sct",
                    "display": "Carrier of muscular dystrophy (finding)"
                },
                {
                    "code": "HP:0003560",
                    "system": "http://human-phenotype-ontology.org",
                    "display": "Muscular dystrophy"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "HP:0000527",
                    "system": "http://human-phenotype-ontology.org",
                    "display": "Long eyelashes"
                }
            ]
        }
    ],
    "reasonReference":  [
        {
            "reference": "Observation/mii-exa-molgen-phenotypic-feature-1"
        },
        {
            "reference": "Observation/mii-exa-molgen-phenotypic-feature-2"
        },
        {
            "reference": "Observation/mii-exa-molgen-phenotypic-feature-3"
        },
        {
            "reference": "Observation/mii-exa-molgen-phenotypic-feature-4"
        }
    ]
}

Beispiel des in der Anforderung 2 referenzierten Specimens (Probe) basierend auf dem Profil des MII Moduls Biobank.

{
    "resourceType": "Specimen",
    "id": "mii-exa-molgen-specimen-2",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-biobank/StructureDefinition/SpecimenCore"
        ]
    },
    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "445295009",
                "display": "Blood specimen with edetic acid (specimen)"
            }
        ]
    },
    "status": "available",
    "subject": {
        "reference": "Patient/mii-exa-molgen-patient-2"
    },
    "receivedTime": "2021-11-24",
    "collection": {
        "collectedDateTime": "2021-11-23"
    },
    "identifier":  [
        {
            "system": "https://www.charite.de/fhir/sid/bioproben",
            "value": "specimen_02"
        }
    ]
}

Beispiel der Anforderung für das Risk-Panel

{
    "resourceType": "ServiceRequest",
    "id": "mii-exa-molgen-anforderung-trurisk-panel",
    "meta": {
        "profile":  [
            "https://www.medizininformatik-initiative.de/fhir/ext/modul-molgen/StructureDefinition/anforderung-genetischer-test"
        ]
    },
    "identifier":  [
        {
            "system": "https://www.charite.de/fhir/auftragsnummern",
            "value": "gen_test_03"
        }
    ],
    "status": "active",
    "intent": "order",
    "category":  [
        {
            "coding":  [
                {
                    "code": "108252007",
                    "system": "http://snomed.info/sct",
                    "display": "Laboratory procedure (procedure)"
                }
            ]
        }
    ],
    "code": {
        "coding":  [
            {
                "code": "405825005",
                "system": "http://snomed.info/sct",
                "display": "Molecular genetic test (procedure)"
            }
        ],
        "text": "Panelanalyse TruRisk®-V3 mit NGS basierter CNV-Analyse Bestimmung des Polygenen Risikoscores (PRS) für Brustkrebs"
    },
    "subject": {
        "reference": "Patient/mii-exa-molgen-patient-brca1"
    },
    "authoredOn": "2022-11-01",
    "requester": {
        "reference": "Practitioner/mii-exa-molgen-practitioner-physician"
    },
    "specimen":  [
        {
            "reference": "Specimen/mii-exa-molgen-specimen-brca1"
        }
    ],
    "reasonCode":  [
        {
            "coding":  [
                {
                    "code": "429740004",
                    "system": "http://snomed.info/sct",
                    "display": "Family history of malignant neoplasm of breast (situation)"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "430705002",
                    "system": "http://snomed.info/sct",
                    "display": "Family history of malignant neoplasm of ovary (situation)"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "ORPHA:145",
                    "system": "http://www.orpha.net",
                    "display": "Hereditary breast and ovarian cancer syndrome"
                }
            ]
        },
        {
            "coding":  [
                {
                    "code": "604370",
                    "system": "http://www.omim.org",
                    "display": "BREAST-OVARIAN CANCER, FAMILIAL, SUSCEPTIBILITY TO, 1; BROVCA1"
                }
            ]
        }
    ]
}