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Packagekbv.basis.with.expansion
Resource TypeDocumentReference
IdDocumentReference_783be93b_f22a_43de_a54f_bdca08e2fdbf.json
FHIR VersionR4

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Narrative

Note: links and images are rebased to the (stated) source

Die FHIR-Instanz des Profils KBV_PR_Base_DocumentReference beschreibt einen Ultraschallbefund vom 01.09.2023 des Gebärmutterhalses. Der Befundbericht ist als PDF-Datei verfügbar und enthält Informationen aus der gynäkologischen Ambulanz eines Krankenhauses.

Source1

{
  "resourceType": "DocumentReference",
  "id": "783be93b-f22a-43de-a54f-bdca08e2fdbf",
  "meta": {
    "profile": [
      "https://fhir.kbv.de/StructureDefinition/KBV_PR_Base_DocumentReference"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<!-- snip (see above) -->"
  },
  "status": "current",
  "docStatus": "preliminary",
  "type": {
    "coding": [
      {
        "version": "2020-02-07T07:55:58",
        "code": "BEFU",
        "system": "http://ihe-d.de/CodeSystems/IHEXDStypeCode",
        "display": "Ergebnisse Diagnostik"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "version": "2021-06-25T13:44:47",
          "code": "BEF",
          "system": "http://ihe-d.de/CodeSystems/IHEXDSclassCode",
          "display": "Befundbericht"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/904e04d0-c9f2-4edd-b734-c3526f015000"
  },
  "date": "2023-09-01T09:35:43+01:00",
  "author": [
    {
      "reference": "Practitioner/20597e0e-cb2a-45b3-95f0-dc3dbdb617c3"
    }
  ],
  "authenticator": {
    "reference": "Practitioner/20597e0e-cb2a-45b3-95f0-dc3dbdb617c3"
  },
  "custodian": {
    "reference": "Organization/cf042e44-086a-4d51-9c77-172f9a972e3b"
  },
  "description": "Ultraschallbefund vom 01.09.2023",
  "securityLabel": [
    {
      "coding": [
        {
          "version": "4.0.1",
          "code": "TREAT",
          "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
          "display": "treatment"
        }
      ]
    }
  ],
  "content": [
    {
      "attachment": {
        "contentType": "application/pdf",
        "language": "de",
        "url": "file:///20230901_PAT/Anlagen/Patient/Patient_9734_Ultraschall_Gebärmutterhals_20230901.pdf",
        "title": "Ultraschall des Gebärmutterhalses",
        "creation": "2023-09-01"
      },
      "format": {
        "code": "urn:ihe:pat:apsr:cancer:cervix:2010",
        "system": "http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem",
        "display": "Anatomic Pathology Structured Report Cancer Cervix"
      }
    }
  ],
  "context": {
    "encounter": [
      {
        "reference": "Encounter/853a6feb-1ds5-5572-42dd-9g5cd40f31321"
      }
    ],
    "facilityType": {
      "coding": [
        {
          "version": "http://snomed.info/sct/11000274103/version/20240515",
          "code": "22549003",
          "system": "http://snomed.info/sct",
          "display": "Hospital-based outpatient gynecology clinic (environment)"
        }
      ]
    },
    "practiceSetting": {
      "coding": [
        {
          "version": "http://snomed.info/sct/11000274103/version/20240515",
          "code": "394586005",
          "system": "http://snomed.info/sct",
          "display": "Gynecology"
        }
      ]
    },
    "sourcePatientInfo": {
      "reference": "Patient/904e04d0-c9f2-4edd-b734-c3526f015000"
    }
  }
}