description: Defines the general pathology report structure for German hospitals with the defined terms by the Medical Informatics Initiative
package_name: de.medizininformatikinitiative.kerndatensatz.patho
derivation: constraint
name: MII_PR_Patho_Report
type: DiagnosticReport
elements:
  category:
    binding: {strength: extensible, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/ValueSet/mii-vs-patho-report-category-hl7'}
    mustSupport: true
    index: 13
  conclusionCode: {mustSupport: true, index: 40}
  meta:
    elements:
      lastUpdated: {mustSupport: true, index: 1}
      profile: {mustSupport: true, index: 2}
  encounter: {mustSupport: true, index: 20}
  specimen: {mustSupport: true, index: 25}
  extension:
    index: 4
    slicing:
      rules: open
      ordered: false
      discriminator:
      - {path: url, type: value}
      min: null
      slices:
        related-report:
          match: {url: null}
          schema: {type: Extension, mustSupport: true, url: 'http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact', index: 5}
          min: 0
  effectiveDateTime: {type: dateTime, mustSupport: true, choiceOf: effective, index: 23}
  status: {mustSupport: true, index: 12}
  result:
    mustSupport: true
    index: 26
    slicing:
      rules: closed
      ordered: true
      discriminator:
      - {path: resolve().code, type: value}
      min: 1
      slices:
        intraoperative-observations:
          match:
            resolve(): {code: null}
          schema:
            short: Reference to intraoperative Observation grouper(s)
            refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-intraoperative-grouper']
            type: Reference
            mustSupport: true
            array: true
            index: 27
            elements:
              reference: {mustSupport: true, index: 28}
            required: [reference]
        macroscopic-observations:
          match:
            resolve(): {code: null}
          schema:
            short: Reference to macroscopic Observation grouper(s)
            refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-macroscopic-grouper']
            type: Reference
            mustSupport: true
            array: true
            index: 29
            elements:
              reference: {mustSupport: true, index: 30}
            required: [reference]
        microscopic-observations:
          match:
            resolve(): {code: null}
          schema:
            short: Reference to microscopic Observation grouper(s)
            refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-microscopic-grouper']
            type: Reference
            mustSupport: true
            array: true
            index: 31
            elements:
              reference: {mustSupport: true, index: 32}
            required: [reference]
        additional-observations:
          match:
            resolve(): {code: null}
          schema:
            short: Reference to any additional Observation grouper(s)
            refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-additional-specified-grouper']
            type: Reference
            mustSupport: true
            array: true
            index: 33
            elements:
              reference: {mustSupport: true, index: 34}
            required: [reference]
        diagnostic-conclusion:
          match:
            resolve(): {code: null}
          schema:
            min: 1
            short: Reference to the 'Diagnostic Conclusion' grouper(s)
            index: 35
            refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-diagnostic-conclusion-grouper']
            type: Reference
            mustSupport: true
            array: true
            elements:
              reference: {mustSupport: true, index: 36}
            _required: true
            required: [reference]
  effective:
    mustSupport: true
    choices: [effectiveDateTime]
    index: 22
  id: {mustSupport: true, index: 0}
  code:
    short: Pathology report code
    mustSupport: true
    index: 14
    elements:
      coding:
        index: 15
        slicing:
          rules: open
          discriminator:
          - {path: $this, type: pattern}
          min: 1
          slices:
            pathology-report:
              match: {code: 60568-3, system: 'http://loinc.org'}
              schema:
                mustSupport: true
                pattern:
                  type: Coding
                  value: {code: 60568-3, system: 'http://loinc.org'}
                _required: true
                index: 16
                elements:
                  system: {mustSupport: true, index: 17}
                  code: {mustSupport: true, index: 18}
                required: [system, code]
    required: [coding]
  identifier:
    mustSupport: true
    index: 6
    slicing:
      rules: open
      discriminator:
      - {path: $this.type, type: pattern}
      min: 1
      slices:
        Set-ID:
          match:
            $this: {type: null}
          schema:
            mustSupport: true
            _required: true
            index: 7
            elements:
              type:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: ACSN, system: 'http://terminology.hl7.org/CodeSystem/v2-0203', display: Accession ID}
                index: 8
              system: {mustSupport: true, index: 9}
              value: {mustSupport: true, index: 10}
            required: [value, type, system]
  presentedForm: {mustSupport: true, index: 41}
  basedOn:
    type: Reference
    short: Reference to respective MII_PR_Patho_Service_Request
    mustSupport: true
    refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-service-request']
    index: 11
  imagingStudy: {mustSupport: true, index: 37}
  media:
    short: Reference to single attached images
    mustSupport: true
    index: 38
    elements:
      link:
        type: Reference
        mustSupport: true
        refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-attached-image']
        index: 39
  subject:
    type: Reference
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Patient']
    index: 19
  performer: {mustSupport: true, index: 24}
  text: {mustSupport: true, index: 3}
package_version: 2025.0.2
extensions:
  related-report: {url: 'http://hl7.org/fhir/StructureDefinition/workflow-relatedArtifact', min: 0, type: Extension, mustSupport: true, index: 5}
class: profile
kind: resource
url: https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report
base: http://hl7.org/fhir/StructureDefinition/DiagnosticReport
version: 2025.0.0
required: [basedOn, identifier, subject, specimen, result, performer]