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: 12 elements: coding: mustSupport: true index: 13 slicing: rules: open discriminator: - {path: $this, type: pattern} min: 1 slices: loinc: match: {code: 18748-4, system: 'http://loinc.org'} schema: mustSupport: true pattern: type: Coding value: {code: 18748-4, system: 'http://loinc.org'} array: true index: 14 min: 0 diagnostic-service-sections: match: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} schema: mustSupport: true pattern: type: Coding value: {code: RAD, system: 'http://terminology.hl7.org/CodeSystem/v2-0074'} array: true index: 15 min: 0 sct: match: {code: '4201000179104', system: 'http://snomed.info/sct'} schema: mustSupport: true pattern: type: Coding value: {code: '4201000179104', system: 'http://snomed.info/sct'} _required: true index: 16 min: 1 max: 1 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: 35 elements: coding: mustSupport: true index: 36 slicing: rules: open discriminator: - {path: $this, type: pattern} min: null slices: icd10-gm: match: {system: 'http://fhir.de/CodeSystem/bfarm/icd-10-gm'} schema: mustSupport: true pattern: type: Coding value: {system: 'http://fhir.de/CodeSystem/bfarm/icd-10-gm'} array: true index: 37 min: 0 sct: match: {system: 'http://snomed.info/sct'} schema: mustSupport: true pattern: type: Coding value: {system: 'http://snomed.info/sct'} array: true index: 38 elements: code: binding: {strength: preferred, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/ValueSet/mii-vs-bildgebung-diagnostic-report-coding'} index: 39 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: 34 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: 22 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 index: 4 _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} elements: extension: mustSupport: true index: 5 slicing: slices: type: match: {} schema: {mustSupport: true, index: 5} reference: match: {} schema: mustSupport: true index: 6 elements: value: choices: [valueReference] index: 8 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 9 extensions: type: {url: null, mustSupport: true, index: 5} reference: url: null mustSupport: true index: 6 elements: value: choices: [valueReference] index: 8 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 9 url: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo effectiveDateTime: type: dateTime mustSupport: true choiceOf: effective index: 27 slicing: slices: effectiveDateTime: match: {} schema: {type: dateTime, mustSupport: true, choiceOf: effective, index: 27} 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: 11 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: 32 effective: mustSupport: true choices: [effectivePeriod] index: 29 slicing: slices: effectivePeriod: match: {} schema: mustSupport: true choices: [effectivePeriod] index: 29 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: 17 elements: coding: index: 18 slicing: rules: open discriminator: - {path: $this, type: pattern} min: null slices: sct: match: {system: 'http://snomed.info/sct'} schema: mustSupport: true pattern: type: Coding value: {system: 'http://snomed.info/sct'} index: 19 min: 0 max: 1 loinc: match: {system: 'http://loinc.org'} schema: mustSupport: true pattern: type: Coding value: {system: 'http://loinc.org'} index: 20 min: 0 max: 1 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: 31 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: 40 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: 10 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: 33 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: 21 effectivePeriod: type: Period mustSupport: true choiceOf: effective index: 30 slicing: slices: effectivePeriod: match: {} schema: {type: Period, mustSupport: true, choiceOf: effective, index: 30} min: 0 max: 1 package_version: 2025.0.1 extensions: supportingInfo: short: Zusatzinformation index: 4 _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} elements: extension: mustSupport: true index: 5 slicing: slices: type: match: {} schema: {mustSupport: true, index: 5} reference: match: {} schema: mustSupport: true index: 6 elements: value: choices: [valueReference] index: 8 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 9 extensions: type: {url: null, mustSupport: true, index: 5} reference: url: null mustSupport: true index: 6 elements: value: choices: [valueReference] index: 8 valueReference: type: Reference choiceOf: value refers: ['http://hl7.org/fhir/StructureDefinition/DiagnosticReport', 'http://hl7.org/fhir/StructureDefinition/Procedure'] index: 9 url: http://hl7.org/fhir/5.0/StructureDefinition/extension-DiagnosticReport.supportingInfo 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: 2025.0.1 required: [imagingStudy, subject, category]