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Packagede.medizininformatikinitiative.kerndatensatz.bildgebung
Resource TypeDiagnosticReport
IdDiagnosticReport-mii-exa-bildgebung-radiologischer-Befund.json
FHIR VersionR4

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Source1

{
  "resourceType": "DiagnosticReport",
  "id": "mii-exa-bildgebung-radiologischer-Befund",
  "meta": {
    "profile": [
      "https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund"
    ]
  },
  "category": [
    {
      "coding": [
        {
          "code": "4201000179104",
          "system": "http://snomed.info/sct"
        }
      ]
    }
  ],
  "extension": [
    {
      "url": "http://hl7.org/fhir/StructureDefinition/workflow-supportingInfo",
      "valueReference": {
        "reference": "DiagnosticReport/DiagRepExample"
      }
    }
  ],
  "basedOn": [
    {
      "reference": "ServiceRequest/mii-exa-bildgebung-anforderung-bildgebung"
    }
  ],
  "status": "final",
  "code": {
    "coding": [
      {
        "code": "4231000179109",
        "system": "http://snomed.info/sct",
        "display": "Mammography report"
      }
    ]
  },
  "subject": {
    "reference": "Patient/PatExample"
  },
  "encounter": {
    "reference": "Encounter/EncExample"
  },
  "effectiveDateTime": "2024-07-19T12:03:30+02:00",
  "issued": "2024-07-19T12:03:30+02:00",
  "result": [
    {
      "reference": "Observation/mii-exa-bildgebung-radiologische-beobachtung"
    }
  ],
  "imagingStudy": [
    {
      "reference": "ImagingStudy/mii-exa-bildgebung-bildgebungsstudie-ct"
    }
  ],
  "conclusion": "There are suspicious microcalcifications in the upper outer quadrant in the left breast",
  "conclusionCode": [
    {
      "coding": [
        {
          "code": "44771000",
          "system": "http://snomed.info/sct",
          "display": "Microcalcifications of the breast (disorder)"
        }
      ]
    }
  ]
}