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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Kategorie} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: Category} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Klassifikation des Befunds als Laborbefund} - 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 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Schlussfolgerung} - 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: de-DE} - {url: content, valueString: Klinische Schlussfolgerung/Interpretation der Testergebnisse} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Fall oder Kontakt} - 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: de-DE} - {url: content, valueString: 'Fall oder Kontakt, bei dem der Laborbefund erstellt wurde.'} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Probenmaterial} - 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: de-DE} - {url: content, valueString: 'Details zu den Bioproben, auf denen dieser Laborbefund basiert.'} - 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: _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Zeitpunkt, zu dem die gemessene Eigenschaft im Probenmaterial e.g. Analytkonzentration mutmaßlich der Eigenschaft im Patienten entsprach.'} - 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: de-DE} - {url: content, valueString: Klinisches Bezugsdatum} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Status} - 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: de-DE} - {url: content, valueString: registriert | teilweise | vorläufig | final} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ergebnis} - 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: de-DE} - {url: content, valueString: 'Laborergebnisse, die Teil dieses Laborbefunds sind.'} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Klinisches Bezugsdatum} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: Clinical reference Date} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Zeitpunkt, zu dem die gemessene Eigenschaft im Probenmaterial e.g. Analytkonzentration mutmaßlich der Eigenschaft im Patienten entsprach.'} - 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] index: 26 id: {mustSupport: true, index: 0} code: _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Code} - 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: de-DE} - {url: content, valueString: Ein LOINC Code zur Identifikation des Befunds als Laborbefund.} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Identifikator} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: Identifier} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Kennung/en, unter der/denen dieser Laborbefund bekannt ist.'} - 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 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Dokumentationsdatum} - 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: de-DE} - {url: content, valueString: 'Zeitpunkt, an dem der Laborbefund dokumentiert wurde.'} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Basiert auf} - 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: de-DE} - {url: content, valueString: 'Bezug zum Laborauftrag, auf dem dieser Laborbefund basiert.'} - 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: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ausführende*r} - 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: de-DE} - {url: content, valueString: 'Verantwortliche Person oder Organisation, die für die Ausstellung des Befunds verantwortlich ist.'} - 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: 2025.0.0-alpha1 class: profile kind: resource url: https://www.medizininformatik-initiative.de/fhir/core/modul-labor/StructureDefinition/DiagnosticReportLab base: http://hl7.org/fhir/StructureDefinition/DiagnosticReport version: 2025.0.0 required: [effectiveDateTime, issued, basedOn, identifier, subject, category, effective, result]