{
"description": "Pathology report which contains the findings and interpretation of a pathology study.",
"_filename": "StructureDefinition-path-Report.json",
"package_name": "medmij.fhir.nl.r4.pathology",
"date": null,
"derivation": "constraint",
"publisher": "MedMij",
"fhirVersion": "4.0.1",
"purpose": "This DiagnosticReport resource represents the Report Clinical Information Model (CIM) for patient use cases in the context of Pathology.",
"name": "PathReport",
"mapping": [ {
"name": "Mercurius Core Dataset 2.0",
"identity": "mercurius-core-dataset-2-0"
}, {
"name": "Dataset MedMij R4 Core 1.2.0 20260923",
"identity": "medmij-core-dataset-120-20260923"
}, {
"name": "Dataset Pathologie MedMij 1.0.0-alpha.3 20260923",
"identity": "path-dataset-100-alpha3-20260923"
} ],
"abstract": false,
"copyright": "Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.",
"type": "DiagnosticReport",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "path Report",
"package_version": "1.0.0-alpha.3",
"status": "draft",
"id": "d04b569a-ca7f-4d7e-bbe4-196055645597",
"kind": "resource",
"url": "http://medmij.nl/fhir/StructureDefinition/path-Report",
"version": "1.0.0-alpha.3",
"differential": {
"element": [ {
"id": "DiagnosticReport",
"path": "DiagnosticReport",
"alias": [ "Verslag", "Test", "Result", "Results", "Labs", "Laboratory" ],
"short": "Report",
"mapping": [ {
"map": "path-dataelement-10",
"comment": "Report",
"identity": "path-dataset-100-alpha3-20260923"
} ],
"constraint": [ {
"key": "path-Report-1",
"human": "Either a code for cytology or histology is present.",
"source": "http://medmij.nl/fhir/StructureDefinition/path-Report",
"severity": "error",
"expression": "code.coding.where(system = 'http://snomed.info/sct' and code = '1348332002').exists() xor code.coding.where(system = 'http://snomed.info/sct' and code = '252416005').exists()"
} ],
"definition": "Pathology report which contains the findings and interpretation of a pathology study."
}, {
"id": "DiagnosticReport.meta",
"min": 1,
"path": "DiagnosticReport.meta"
}, {
"id": "DiagnosticReport.meta.tag",
"min": 1,
"path": "DiagnosticReport.meta.tag",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
}
}, {
"path": "DiagnosticReport.meta.tag",
"min": 1,
"definition": "The type of the healthcare provider responsible for the delivered care, or more specifically, the specialty of the department and/or health professional that delivered care. It enables patients and systems to interpret the origin and context of medical data.",
"short": "CareType",
"mapping": [ {
"map": "medmij-core-dataelement-123",
"comment": "CareType",
"identity": "medmij-core-dataset-120-20260923"
} ],
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
},
"sliceName": "careType",
"binding": {
"strength": "required",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.17.2.4--20200901000000"
},
"alias": [ "Zorgtype" ],
"max": "*",
"id": "DiagnosticReport.meta.tag:careType",
"comment": "Note that the `careType` slice is a slice on `.meta.tag`, which might not be immediately clear based on the rendering."
}, {
"id": "DiagnosticReport.meta.tag:careType/pathology",
"max": "1",
"min": 1,
"path": "DiagnosticReport.meta.tag",
"comment": "Note that the `pathology` slice is a reslice of the `careType` slice, which might not be immediately clear based on the rendering.",
"sliceName": "careType/pathology",
"patternCoding": {
"code": "0388",
"system": "urn:oid:2.16.840.1.113883.2.4.6.7"
}
}, {
"id": "DiagnosticReport.identifier",
"min": 1,
"path": "DiagnosticReport.identifier",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "profile"
} ]
}
}, {
"id": "DiagnosticReport.identifier:reportIdentifier",
"max": "1",
"min": 1,
"path": "DiagnosticReport.identifier",
"type": [ {
"code": "Identifier",
"profile": [ "http://medmij.nl/fhir/StructureDefinition/path-Report.ReportIdentifier" ]
} ],
"sliceName": "reportIdentifier"
}, {
"id": "DiagnosticReport.basedOn",
"max": "1",
"min": 1,
"path": "DiagnosticReport.basedOn",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/ServiceRequest", "http://medmij.nl/fhir/StructureDefinition/path-Request" ]
} ]
}, {
"id": "DiagnosticReport.status",
"path": "DiagnosticReport.status",
"patternCode": "final"
}, {
"id": "DiagnosticReport.category",
"min": 1,
"path": "DiagnosticReport.category",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
}
}, {
"id": "DiagnosticReport.category:pathology",
"max": "1",
"min": 1,
"path": "DiagnosticReport.category",
"sliceName": "pathology",
"patternCodeableConcept": {
"coding": [ {
"code": "108257001",
"system": "http://snomed.info/sct"
} ]
}
}, {
"id": "DiagnosticReport.code",
"path": "DiagnosticReport.code",
"comment": "If the pathology study is of type cytology (which means that the ReportIdentifier (i.e. _rapnaam_, mercurius-core-rubriek-3) starts with either _B_ or _C_, corresponding to cervical cytology and other cytology, respectively), SNOMED CT code _1348332002_ SHALL be used as `.code`. Likewise, if the study is of type histology (in which case the ReportIdentifier starts with _T_), SNOMED CT code _252416005_ SHALL be used instead. Studies for which the ReportIdentifier starts with _S_ (i.e. autopsies) are out of scope."
}, {
"id": "DiagnosticReport.code.coding",
"min": 1,
"path": "DiagnosticReport.code.coding",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
}
}, {
"id": "DiagnosticReport.code.coding:cytology",
"max": "1",
"min": 0,
"path": "DiagnosticReport.code.coding",
"condition": [ "path-Report-1" ],
"sliceName": "cytology",
"patternCoding": {
"code": "1348332002",
"system": "http://snomed.info/sct"
}
}, {
"id": "DiagnosticReport.code.coding:histology",
"max": "1",
"min": 0,
"path": "DiagnosticReport.code.coding",
"condition": [ "path-Report-1" ],
"sliceName": "histology",
"patternCoding": {
"code": "252416005",
"system": "http://snomed.info/sct"
}
}, {
"id": "DiagnosticReport.subject",
"min": 1,
"path": "DiagnosticReport.subject",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://medmij.nl/fhir/StructureDefinition/path-Patient" ]
} ],
"alias": [ "Patiënt" ],
"short": "Patient",
"mapping": [ {
"map": "medmij-core-dataelement-116",
"comment": "Patient",
"identity": "medmij-core-dataset-120-20260923"
} ],
"definition": "The patient as subject of the information."
}, {
"id": "DiagnosticReport.effective[x]",
"min": 1,
"path": "DiagnosticReport.effective[x]",
"slicing": {
"rules": "open",
"ordered": false,
"discriminator": [ {
"path": "$this",
"type": "type"
} ]
}
}, {
"id": "DiagnosticReport.effective[x]:effectivePeriod",
"max": "1",
"min": 1,
"path": "DiagnosticReport.effective[x]",
"type": [ {
"code": "Period"
} ],
"sliceName": "effectivePeriod"
}, {
"id": "DiagnosticReport.effective[x]:effectivePeriod.start",
"min": 1,
"path": "DiagnosticReport.effective[x].start",
"alias": [ "DatumOntvangst" ],
"short": "ReceivedDate",
"mapping": [ {
"map": "mercurius-core-rubriek-80",
"comment": "datumontvangst",
"identity": "mercurius-core-dataset-2-0"
} ],
"definition": "Date when specimen is received at the laboratory."
}, {
"id": "DiagnosticReport.effective[x]:effectivePeriod.end",
"min": 1,
"path": "DiagnosticReport.effective[x].end",
"alias": [ "Tijdsindicatie", "DatumTijd", "DatumAutorisatie" ],
"short": "EffectiveDateTime / AuthorizationDate",
"mapping": [ {
"map": "mercurius-core-rubriek-44",
"comment": "datumautorisatie",
"identity": "mercurius-core-dataset-2-0"
}, {
"map": "medmij-core-dataelement-119",
"comment": "EffectiveDateTime",
"identity": "medmij-core-dataset-120-20260923"
} ],
"definition": "Date of authorization."
}, {
"path": "DiagnosticReport.resultsInterpreter",
"min": 1,
"definition": "Name of the pathologist who has authorized the report.",
"short": "Authorizer",
"mapping": [ {
"map": "mercurius-core-rubriek-41",
"comment": "autorisator (implicit, actual mapping is on Practitioner.name[nameInformation].text)",
"identity": "mercurius-core-dataset-2-0"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-Practitioner", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole" ]
} ],
"alias": [ "Autorisator", "Reported by" ],
"max": "1",
"id": "DiagnosticReport.resultsInterpreter",
"comment": "The actual mapping of the Authorizer concept is on `Practitioner.name[nameInformation].text`."
}, {
"id": "DiagnosticReport.specimen",
"min": 1,
"path": "DiagnosticReport.specimen",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Specimen", "http://medmij.nl/fhir/StructureDefinition/path-Request.Specimen" ]
} ],
"alias": [ "Monster" ],
"short": "Specimen",
"comment": "Both the primary specimen as well as the individual samples taken from that specimen are referenced here. If only a single sample is taken, precisely one Specimen is referenced here, as the primary specimen and sample coincide in that case.",
"definition": "Specimen that will be examined by a laboratory."
}, {
"path": "DiagnosticReport.result",
"min": 1,
"definition": "Data from National Palga Protocols, created in the Palga Protocol Module.",
"short": "ProtocolData",
"mapping": [ {
"map": "mercurius-core-rubriek-308",
"comment": "protocoldata",
"identity": "mercurius-core-dataset-2-0"
} ],
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve().code",
"type": "value"
} ]
},
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Observation", "http://medmij.nl/fhir/StructureDefinition/path-Report.ProtocolDataItem" ]
} ],
"alias": [ "Protocoldata", "Atomic Value", "Result", "Atomic result", "Data", "Test", "Analyte", "Battery", "Organizer" ],
"id": "DiagnosticReport.result",
"comment": "Note that the protocol data has not been defined as a separate slice in this profile, as possibly any SNOMED CT code could be present in the `.code` element of an Observation corresponding to a protocol data item, which makes proper discrimination unfeasible."
}, {
"id": "DiagnosticReport.result:clinicalInformation",
"max": "1",
"min": 0,
"path": "DiagnosticReport.result",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://medmij.nl/fhir/StructureDefinition/path-Report.ClinicalInformation" ]
} ],
"sliceName": "clinicalInformation"
}, {
"id": "DiagnosticReport.result:macroscopy",
"max": "1",
"min": 0,
"path": "DiagnosticReport.result",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://medmij.nl/fhir/StructureDefinition/path-Report.Macroscopy" ]
} ],
"sliceName": "macroscopy"
}, {
"id": "DiagnosticReport.result:microscopy",
"max": "1",
"min": 1,
"path": "DiagnosticReport.result",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://medmij.nl/fhir/StructureDefinition/path-Report.Microscopy" ]
} ],
"sliceName": "microscopy"
}, {
"id": "DiagnosticReport.conclusion",
"min": 1,
"path": "DiagnosticReport.conclusion",
"alias": [ "Conclusie" ],
"short": "Conclusion",
"mapping": [ {
"map": "mercurius-core-rubriek-224",
"comment": "conclusie",
"identity": "mercurius-core-dataset-2-0"
} ],
"definition": "Conclusion of the report."
} ]
},
"contact": [ {
"name": "MedMij",
"telecom": [ {
"use": "work",
"value": "info@medmij.nl",
"system": "email"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport"
}