{ "description": "Diese Ressource beschreibt einen radiologischen Befund", "_filename": "StructureDefinition-mii-pr-bildgebung-radiologischer-befund.json", "package_name": "de.medizininformatikinitiative.kerndatensatz.bildgebung", "date": "2025-03-28", "derivation": "constraint", "publisher": "Medizininformatik Initiative", "fhirVersion": "4.0.1", "name": "MII_PR_Bildgebung_Radiologischer_Befund", "abstract": false, "type": "DiagnosticReport", "experimental": null, "resourceType": "StructureDefinition", "title": "MII PR Bildgebung Radiologischer Befund", "_description": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Darstellung des Befundberichts" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "The profile describes a diagnostic report for a radiological image." } ] } ] }, "package_version": "2025.0.1", "extension": [ { "url": "https://www.medizininformatik-initiative.de/fhir/modul-meta/StructureDefinition/mii-ex-meta-license-codeable", "valueCodeableConcept": { "coding": [ { "code": "CC-BY-4.0", "system": "http://hl7.org/fhir/spdx-license", "display": "Creative Commons Attribution 4.0 International" } ] } } ], "status": "active", "id": "e9ffebbe-8375-4ff4-97b4-172eb5a585ec", "kind": "resource", "_name": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "MII_PR_Imaging_Diagnostic_Report" } ] } ] }, "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund", "_title": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Befundbericht" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "diagnostic report" } ] } ] }, "version": "2025.0.1", "differential": { "element": [ { "id": "DiagnosticReport.id", "path": "DiagnosticReport.id", "mustSupport": true }, { "id": "DiagnosticReport.meta", "path": "DiagnosticReport.meta", "mustSupport": true }, { "id": "DiagnosticReport.meta.source", "path": "DiagnosticReport.meta.source", "mustSupport": true }, { "id": "DiagnosticReport.meta.profile", "path": "DiagnosticReport.meta.profile", "mustSupport": true }, { "path": "DiagnosticReport.extension", "min": 0, "definition": "Zusatzinformation zum Befundbericht", "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": [ { "code": "Extension", "profile": [ "http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo" ] } ], "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" } ] } ] }, "sliceName": "supportingInfo", "max": "*", "id": "DiagnosticReport.extension:supportingInfo" }, { "id": "DiagnosticReport.extension:supportingInfo.extension:type", "path": "DiagnosticReport.extension.extension", "sliceName": "type", "mustSupport": true }, { "id": "DiagnosticReport.extension:supportingInfo.extension:reference", "path": "DiagnosticReport.extension.extension", "sliceName": "reference", "mustSupport": true }, { "id": "DiagnosticReport.extension:supportingInfo.extension:reference.value[x]", "path": "DiagnosticReport.extension.extension.value[x]", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DiagnosticReport", "http://hl7.org/fhir/StructureDefinition/Procedure" ] } ] }, { "id": "DiagnosticReport.basedOn", "path": "DiagnosticReport.basedOn", "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-anforderung-bildgebung", "http://hl7.org/fhir/StructureDefinition/CarePlan" ] } ], "short": "Anforderung", "_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" } ] } ] }, "definition": "Anforderung, die den Befundbericht ausgelöst hat", "_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" } ] } ] }, "mustSupport": true }, { "id": "DiagnosticReport.status", "path": "DiagnosticReport.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": "angemeldet | unvollständig | vorläufig | endgültig | geändert | korrigiert | angefügt | abgebrochen | fehlerhafte Eingabe | unbekannt", "_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 }, { "id": "DiagnosticReport.category", "min": 1, "path": "DiagnosticReport.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": "Kategorie des Befundberichts", "_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 }, { "id": "DiagnosticReport.category.coding", "min": 1, "path": "DiagnosticReport.category.coding", "slicing": { "rules": "open", "discriminator": [ { "path": "$this", "type": "pattern" } ] }, "mustSupport": true }, { "id": "DiagnosticReport.category.coding:loinc", "max": "*", "min": 0, "path": "DiagnosticReport.category.coding", "sliceName": "loinc", "mustSupport": true, "patternCoding": { "code": "18748-4", "system": "http://loinc.org" } }, { "id": "DiagnosticReport.category.coding:diagnostic-service-sections", "max": "*", "min": 0, "path": "DiagnosticReport.category.coding", "sliceName": "diagnostic-service-sections", "mustSupport": true, "patternCoding": { "code": "RAD", "system": "http://terminology.hl7.org/CodeSystem/v2-0074" } }, { "id": "DiagnosticReport.category.coding:sct", "max": "1", "min": 1, "path": "DiagnosticReport.category.coding", "sliceName": "sct", "mustSupport": true, "patternCoding": { "code": "4201000179104", "system": "http://snomed.info/sct" } }, { "id": "DiagnosticReport.code", "path": "DiagnosticReport.code", "short": "Code", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Code" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "code" } ] } ] }, "definition": "Code des Befundberichts", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Code des Befundberichts" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "code of the diagnostic report" } ] } ] }, "mustSupport": true }, { "id": "DiagnosticReport.code.coding", "path": "DiagnosticReport.code.coding", "slicing": { "rules": "open", "discriminator": [ { "path": "$this", "type": "pattern" } ] } }, { "id": "DiagnosticReport.code.coding:sct", "max": "1", "min": 0, "path": "DiagnosticReport.code.coding", "sliceName": "sct", "mustSupport": true, "patternCoding": { "system": "http://snomed.info/sct" } }, { "id": "DiagnosticReport.code.coding:loinc", "max": "1", "min": 0, "path": "DiagnosticReport.code.coding", "sliceName": "loinc", "mustSupport": true, "patternCoding": { "system": "http://loinc.org" } }, { "path": "DiagnosticReport.subject", "min": 1, "definition": "Person, auf die sich die Befundbericht bezieht", "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" } ] } ] }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ] } ], "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" } ] } ] }, "id": "DiagnosticReport.subject" }, { "id": "DiagnosticReport.encounter", "path": "DiagnosticReport.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": "Fall-Referenz auf den Versorgungssstellenkontakt", "_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 }, { "id": "DiagnosticReport.effective[x]", "path": "DiagnosticReport.effective[x]", "short": "Erstellungsdatum", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Erstellungsdatum" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "effective[x]" } ] } ] }, "slicing": { "rules": "open", "ordered": false, "discriminator": [ { "path": "$this", "type": "type" } ] }, "definition": "Zeitpunkt der Erstellung", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "de-DE" }, { "url": "content", "valueString": "Zeitpunkt der Erstellung" } ] }, { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en-US" }, { "url": "content", "valueString": "date of creation" } ] } ] }, "mustSupport": true }, { "id": "DiagnosticReport.effective[x]:effectiveDateTime", "max": "1", "min": 0, "path": "DiagnosticReport.effective[x]", "type": [ { "code": "dateTime" } ], "sliceName": "effectiveDateTime", "mustSupport": true }, { "id": "DiagnosticReport.effective[x]:effectivePeriod", "max": "1", "min": 0, "path": "DiagnosticReport.effective[x]", "type": [ { "code": "Period" } ], "sliceName": "effectivePeriod", "mustSupport": true }, { "id": "DiagnosticReport.issued", "path": "DiagnosticReport.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": "Zeit an der der Bericht erstellt wurde", "_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 }, { "id": "DiagnosticReport.result", "path": "DiagnosticReport.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": "Ergebnis einer Beobachtung", "_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 }, { "path": "DiagnosticReport.imagingStudy", "min": 1, "definition": "Studie, die die vollständige Bildgebung umfasst", "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" } ] } ] }, "type": [ { "code": "Reference", "targetProfile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-bildgebungsstudie" ] } ], "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" } ] } ] }, "id": "DiagnosticReport.imagingStudy" }, { "id": "DiagnosticReport.conclusion", "path": "DiagnosticReport.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": "Fazit zur aktuellen Befundung", "_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 }, { "id": "DiagnosticReport.conclusionCode", "path": "DiagnosticReport.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": "Fazit, welches strukturiert über Codes dargestellt wird", "_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 }, { "id": "DiagnosticReport.conclusionCode.coding", "path": "DiagnosticReport.conclusionCode.coding", "slicing": { "rules": "open", "discriminator": [ { "path": "$this", "type": "pattern" } ] }, "mustSupport": true }, { "id": "DiagnosticReport.conclusionCode.coding:icd10-gm", "max": "*", "min": 0, "path": "DiagnosticReport.conclusionCode.coding", "sliceName": "icd10-gm", "mustSupport": true, "patternCoding": { "system": "http://fhir.de/CodeSystem/bfarm/icd-10-gm" } }, { "id": "DiagnosticReport.conclusionCode.coding:sct", "max": "*", "min": 0, "path": "DiagnosticReport.conclusionCode.coding", "sliceName": "sct", "mustSupport": true, "patternCoding": { "system": "http://snomed.info/sct" } }, { "id": "DiagnosticReport.conclusionCode.coding:sct.code", "path": "DiagnosticReport.conclusionCode.coding.code", "binding": { "strength": "preferred", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-coding" } }, { "id": "DiagnosticReport.presentedForm", "path": "DiagnosticReport.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": "zusätzlicher wichtiger Anhang", "_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 } ] }, "contact": [ { "telecom": [ { "value": "https://www.medizininformatik-initiative.de", "system": "url" } ] } ], "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport" }