description: Diese Ressource beschreibt einen radiologischen Befund package_name: de.medizininformatikinitiative.kerndatensatz.bildgebung derivation: constraint name: MII_PR_Bildgebung_Radiologischer_Befund type: DiagnosticReport elements: category: short: Kategorie _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: Kategorie des Befundberichts} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: category of the diagnostic report} mustSupport: true index: 11 elements: coding: mustSupport: true index: 12 elements: system: {mustSupport: true, index: 13} code: {mustSupport: true, index: 14} required: [system, code] slicing: rules: open discriminator: - {path: $this, type: pattern} min: 1 slices: loinc: match: {code: 18748-4, system: 'http://loinc.org'} schema: short: LOINC Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von LOINC definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by LOINC} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: LOINC Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: LOINC code} pattern: type: Coding value: {code: 18748-4, system: 'http://loinc.org'} index: 15 elements: system: {mustSupport: true, index: 16} code: {mustSupport: true, index: 17} display: pattern: {type: String, value: Diagnostic imaging study} index: 18 required: [system, code] diagnostic-service-sections: match: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} schema: short: Diagnostic Service Section Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von HL7 International definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by HL7 International} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Diagnostische Serviceabteilung Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: Diagnostic-service-section code} pattern: type: Coding value: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} index: 19 elements: system: {mustSupport: true, index: 20} code: {mustSupport: true, index: 21} display: pattern: {type: String, value: Radiology} index: 22 required: [system, code] sct: match: {code: '4201000179104', system: 'http://snomed.info/sct'} schema: short: SNOMED CT Code index: 23 _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von SNOMED CT definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by SNOMED CT} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: SNOMED CT Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: SNOMED CT code} elements: system: {mustSupport: true, index: 24} code: {mustSupport: true, index: 25} display: pattern: {type: String, value: Imaging report (record artifact)} index: 26 _required: true required: [system, code] pattern: type: Coding value: {code: '4201000179104', system: 'http://snomed.info/sct'} required: [coding] conclusionCode: short: Strukturiertes Fazit _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Strukturiertes Fazit} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: structured conclusion} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Fazit, welches strukturiert über Codes dargestellt wird'} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: conclusion presented with structured codes} mustSupport: true index: 47 elements: coding: mustSupport: true index: 48 elements: system: {mustSupport: true, index: 49} code: {mustSupport: true, index: 50} required: [system, code] slicing: rules: open discriminator: - {path: $this, type: pattern} min: 1 slices: icd10-gm: match: {system: 'http://fhir.de/CodeSystem/bfarm/icd-10-gm'} schema: short: ICD-10-GM Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen vom Bundesinstitut für Arzneimittel und Medizinprodukte definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by the german Federal Institute for Drugs and Medical Devices} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: ICD-10-GM Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: ICD-10-GM code} binding: {strength: required, valueSet: 'http://fhir.de/ValueSet/bfarm/icd-10-gm'} pattern: type: Coding value: {system: 'http://fhir.de/CodeSystem/bfarm/icd-10-gm'} index: 51 min: 0 max: 1 sct: match: {system: 'http://snomed.info/sct'} schema: short: SNOMED CT Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von SNOMED CT definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by SNOMED CT} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: SNOMED CT Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: SNOMED CT code} binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-findings-sct'} pattern: type: Coding value: {system: 'http://snomed.info/sct'} index: 52 min: 0 max: 1 required: [coding] conclusion: short: Fazit _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Fazit} - 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: Fazit zur aktuellen Befundung} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: conclusion of the actual report} mustSupport: true index: 46 meta: mustSupport: true index: 1 elements: source: {mustSupport: true, index: 2} profile: {mustSupport: true, index: 3} encounter: short: Versorgungssstellenkontakt _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Versorgungssstellenkontakt} - 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-Referenz auf den Versorgungssstellenkontakt} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: encounter reference} mustSupport: true index: 34 extension: index: 4 slicing: rules: open ordered: false discriminator: - {path: url, type: value} min: null slices: supportingInfo: match: {url: null} schema: short: Zusatzinformation _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Zusatzinformation zum Befundbericht} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: additional information for the report} type: Extension mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Zusatzinformation} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: additional information} url: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo index: 5 elements: value: choices: [valueReference] index: 7 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 8 effectiveDateTime: type: dateTime mustSupport: true choiceOf: effective index: 39 slicing: slices: effectiveDateTime: match: {} schema: {type: dateTime, mustSupport: true, choiceOf: effective, index: 39} min: 0 max: 1 status: short: 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: angemeldet | unvollständig | vorläufig | endgültig | geändert | korrigiert | angefügt | abgebrochen | fehlerhafte Eingabe | unbekannt} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown} mustSupport: true index: 10 result: short: Ergebnis _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: Ergebnis einer Beobachtung} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: result of an observation} mustSupport: true index: 44 effective: mustSupport: true choices: [effectivePeriod] index: 41 slicing: slices: effectivePeriod: match: {} schema: mustSupport: true choices: [effectivePeriod] index: 41 min: 0 max: 1 id: {mustSupport: true, index: 0} code: short: 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: Code des Befundberichts} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: code of the diagnostic report} mustSupport: true index: 27 elements: coding: mustSupport: true index: 28 elements: system: {mustSupport: true, index: 29} code: {mustSupport: true, index: 30} required: [system, code] slicing: rules: open discriminator: - {path: $this, type: pattern} min: 1 slices: sct: match: {system: 'http://snomed.info/sct'} schema: short: SNOMED CT Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von SNOMED CT definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by SNOMED CT} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: SNOMED CT Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: SNOMED CT code} binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-code-sct'} pattern: type: Coding value: {system: 'http://snomed.info/sct'} index: 31 min: 0 max: 1 loinc: match: {system: 'http://loinc.org'} schema: short: LOINC Code _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Ein Verweis auf einen von LOINC definierten Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: A reference to a code defined by LOINC} mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: LOINC Code} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: LOINC code} binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-code-lnc'} pattern: type: Coding value: {system: 'http://loinc.org'} index: 32 min: 0 max: 1 required: [coding] issued: short: Erstellungszeitpunkt _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Erstellungszeitpunkt} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: time of creation} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Zeit an der der Bericht erstellt wurde} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: timestamp of creation of the report} mustSupport: true index: 43 presentedForm: short: Anhang _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Anhang} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: Attachment} _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: zusätzlicher wichtiger Anhang} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: additional attachment to the report} mustSupport: true index: 53 basedOn: short: Anforderung _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Anforderung, die den Befundbericht ausgelöst hat'} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: 'request, which triggered the report'} refers: ['http://hl7.org/fhir/StructureDefinition/CarePlan', 'https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-anforderung-bildgebung'] type: Reference mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Anforderung} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: request} index: 9 imagingStudy: short: Bildgebungsstudie _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Studie, die die vollständige Bildgebung umfasst'} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: study with all images} refers: ['https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-bildgebungsstudie'] type: Reference mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Bildgebungsstudie} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: imaging study} index: 45 subject: short: Person _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: 'Person, auf die sich die Befundbericht bezieht'} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: 'person, which this report is about'} refers: ['http://hl7.org/fhir/StructureDefinition/Patient'] type: Reference mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Person} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: person} index: 33 effectivePeriod: type: Period mustSupport: true choiceOf: effective index: 42 slicing: slices: effectivePeriod: match: {} schema: {type: Period, mustSupport: true, choiceOf: effective, index: 42} min: 0 max: 1 package_version: 2027.0.0-ballot.rc1 extensions: supportingInfo: url: http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo short: Zusatzinformation _definition: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Zusatzinformation zum Befundbericht} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: additional information for the report} type: Extension mustSupport: true _short: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: de-DE} - {url: content, valueString: Zusatzinformation} - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en-US} - {url: content, valueString: additional information} index: 5 elements: value: choices: [valueReference] index: 7 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 8 class: profile kind: resource url: https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund base: http://hl7.org/fhir/StructureDefinition/DiagnosticReport version: 2027.0.0-ballot required: [imagingStudy, subject, category]