description: Dieses Profil beschreibt einen Laborbefund in der Medizininformatik-Initiative.
package_name: de.medizininformatikinitiative.kerndatensatz.laborbefund
derivation: constraint
name: MII_PR_Labor_Laborbefund
type: DiagnosticReport
elements:
  category:
    short: Kategorie
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Classification of the report as laboratory report}
    mustSupport: true
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Category}
    index: 16
    elements:
      coding:
        mustSupport: true
        array: true
        min: 2
        index: 17
        slicing:
          rules: open
          discriminator:
          - {path: $this, type: pattern}
          min: 2
          slices:
            loinc-lab:
              match: {code: 26436-6, system: 'http://loinc.org'}
              schema:
                mustSupport: true
                pattern:
                  type: Coding
                  value: {code: 26436-6, system: 'http://loinc.org'}
                _required: true
                index: 18
              min: 1
              max: 1
            diagnostic-service-sections:
              match: {code: LAB, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'}
              schema:
                mustSupport: true
                pattern:
                  type: Coding
                  value: {code: LAB, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'}
                _required: true
                index: 19
              min: 1
              max: 1
  conclusion:
    short: Schlussfolgerung
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Conclusion}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Clinical conclusion/interpretation of test results}
    mustSupport: true
    index: 37
  meta:
    mustSupport: true
    index: 1
    elements:
      source: {mustSupport: true, index: 2}
      profile: {mustSupport: true, index: 3}
  encounter:
    short: Fall oder Kontakt
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Encounter}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Encounter during which the laboratory report was created.}
    mustSupport: true
    index: 24
  specimen:
    short: Probenmaterial
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Specimen}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Details about the specimens on which this diagnostic report is based.}
    mustSupport: true
    index: 33
    elements:
      reference: {mustSupport: true, index: 34}
      identifier: {mustSupport: true, index: 35}
  effective[x]:
    extensions:
      QuelleKlinischesBezugsdatum: {url: 'https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/QuelleKlinischesBezugsdatum', min: 0, max: 1, type: Extension, mustSupport: true, index: 28}
    elements:
      extension:
        type: Extension
        mustSupport: true
        url: https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/QuelleKlinischesBezugsdatum
        index: 28
        slicing:
          slices:
            QuelleKlinischesBezugsdatum:
              match: {}
              schema: {type: Extension, mustSupport: true, url: 'https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/QuelleKlinischesBezugsdatum', index: 28}
              min: 0
              max: 1
  effectiveDateTime:
    short: Klinisches Bezugsdatum
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: The time when the measured property in the specimen material e.g. analyte concentration is presumed to pertain to the patient.}
    type: dateTime
    mustSupport: true
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Clinical reference Date}
    choiceOf: effective
    index: 27
  status:
    short: Status
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Status}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: registered | partial | preliminary | final}
    mustSupport: true
    index: 15
  result:
    short: Ergebnis
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Result}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Laboratory test results that are part of this diagnostic report.}
    mustSupport: true
    index: 36
  effective:
    short: Klinisches Bezugsdatum
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: The time when the measured property in the specimen material e.g. analyte concentration is presumed to pertain to the patient.}
    mustSupport: true
    choices: [effectiveDateTime]
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Clinical reference Date}
    index: 26
  id: {mustSupport: true, index: 0}
  code:
    short: Code
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Code}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: A LOINC code identifying the report as laboratory report.}
    mustSupport: true
    index: 20
    elements:
      coding:
        mustSupport: true
        index: 21
        slicing:
          rules: open
          discriminator:
          - {path: $this, type: pattern}
          min: 1
          slices:
            loinc-labReport:
              match: {code: 11502-2, system: 'http://loinc.org'}
              schema:
                mustSupport: true
                pattern:
                  type: Coding
                  value: {code: 11502-2, system: 'http://loinc.org'}
                _required: true
                index: 22
              min: 1
              max: 1
    required: [coding]
  identifier:
    short: Identifikator
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Identifier/s by which this laboratory report is known.}
    mustSupport: true
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Identifier}
    index: 4
    slicing:
      rules: open
      discriminator:
      - {path: type, type: pattern}
      min: 1
      slices:
        befund:
          match:
            type:
              coding:
              - {code: FILL, system: 'http://terminology.hl7.org/CodeSystem/v2-0203'}
          schema:
            _required: true
            index: 5
            elements:
              type:
                mustSupport: true
                pattern:
                  type: CodeableConcept
                  value:
                    coding:
                    - {code: FILL, system: 'http://terminology.hl7.org/CodeSystem/v2-0203'}
                index: 6
                elements:
                  coding:
                    mustSupport: true
                    index: 7
                    slicing:
                      rules: open
                      discriminator:
                      - {path: system, type: value}
                      min: 1
                      slices:
                        fillerV2:
                          match: {system: 'http://terminology.hl7.org/CodeSystem/v2-0203'}
                          schema:
                            mustSupport: true
                            _required: true
                            index: 8
                            elements:
                              system:
                                pattern: {type: Uri, value: 'http://terminology.hl7.org/CodeSystem/v2-0203'}
                                mustSupport: true
                                index: 9
                              code:
                                pattern: {type: Code, value: FILL}
                                mustSupport: true
                                index: 10
                            required: [system, code]
                required: [coding]
              system: {mustSupport: true, index: 11}
              value: {mustSupport: true, index: 12}
              assigner: {mustSupport: true, index: 13}
            required: [assigner, value, type, system]
  issued:
    short: Dokumentationsdatum
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Issued}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: The time when the laboratory report was documented.}
    mustSupport: true
    index: 29
  basedOn:
    short: Basiert auf
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Based on}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Reference to the laboratory order on which this laboratory report is based.}
    mustSupport: true
    index: 14
  subject: {mustSupport: true, index: 23}
  performer:
    short: Ausführende*r
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: Performer}
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en-US}
        - {url: content, valueString: The diagnostic service that is responsible for issuing the report.}
    mustSupport: true
    index: 30
    elements:
      reference: {mustSupport: true, index: 31}
      identifier: {mustSupport: true, index: 32}
package_version: 2025.0.2
class: profile
kind: resource
url: https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/DiagnosticReportLab
base: http://hl7.org/fhir/StructureDefinition/DiagnosticReport
version: 2025.0.2
required: [effectiveDateTime, issued, basedOn, identifier, subject, category, effective, result]