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: 7 elements: coding: mustSupport: true index: 8 elements: system: {mustSupport: true, index: 9} code: {mustSupport: true, index: 10} required: [code, system] slicing: rules: open discriminator: - {path: $this, type: pattern} min: 1 slices: loinc: match: {code: 18748-4, system: 'http://loinc.org'} schema: short: LOINC Code index: 11 _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} type: Coding 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} elements: system: {mustSupport: true, index: 12} code: {mustSupport: true, index: 13} display: pattern: {type: string, value: Diagnostic imaging study} type: string index: 14 required: [code, system] pattern: type: Coding value: {code: 18748-4, system: 'http://loinc.org'} diagnostic-service-sections: match: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} schema: short: Diagnostic Service Section Code index: 15 _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} type: Coding 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} elements: system: {mustSupport: true, index: 16} code: {mustSupport: true, index: 17} display: pattern: {type: string, value: Radiology} type: string index: 18 required: [code, system] pattern: type: Coding value: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} sct: match: {code: '4201000179104', system: 'http://snomed.info/sct'} schema: short: SNOMED CT Code index: 19 _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} type: Coding 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: 20} code: {mustSupport: true, index: 21} display: pattern: {type: string, value: Imaging report (record artifact)} type: string index: 22 _required: true required: [code, system] 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: 43 elements: coding: mustSupport: true index: 44 elements: system: {mustSupport: true, index: 45} code: {mustSupport: true, index: 46} required: [code, system] 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'} type: Coding index: 47 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'} type: Coding index: 48 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: 42 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: 30 extension: 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/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo index: 4 slicing: slices: supportingInfo: match: {} 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/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo index: 4 min: 0 effectiveDateTime: type: dateTime mustSupport: true choiceOf: effective index: 35 slicing: slices: effectiveDateTime: match: {} schema: {type: dateTime, mustSupport: true, choiceOf: effective, index: 35} 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: 6 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: 40 effective: mustSupport: true choices: [effectivePeriod] index: 37 slicing: slices: effectivePeriod: match: {} schema: mustSupport: true choices: [effectivePeriod] index: 37 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: 23 elements: coding: mustSupport: true index: 24 elements: system: {mustSupport: true, index: 25} code: {mustSupport: true, index: 26} required: [code, system] 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'} type: Coding index: 27 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'} type: Coding index: 28 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: 39 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: 49 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: 5 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: 41 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: 29 effectivePeriod: type: Period mustSupport: true choiceOf: effective index: 38 slicing: slices: effectivePeriod: match: {} schema: {type: Period, mustSupport: true, choiceOf: effective, index: 38} min: 0 max: 1 package_version: 2026.0.0-ballot extensions: supportingInfo: url: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo min: 0 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: 4 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: 2026.0.0-ballot required: [category, imagingStudy, subject]