German Dental FHIR Profiles (R4) - Local Development build (v0.36.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
Resource Profile: Zahnärztlicher Röntgenbefundbericht (DE)
| Official URL: https://fhir.cognovis.de/dental/StructureDefinition/dental-imaging-diagnostic-report | Version: 0.36.1 | |||
| Active as of 2026-05-30 | Computable Name: DentalImagingDiagnosticReportDE | |||
Copyright/Legal: Copyright 2026+ cognovis GmbH. Licensed under CC-BY-4.0. |
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Profil für zahnärztliche Röntgenbefundberichte. Verbindet eine oder mehrere Röntgenaufnahmen (DentalImagingStudyDE) mit optionalen DentalFindingDE-Einzelbefunden und dem befundenden Zahnarzt.
Usages:
- Examples for this Profile: DiagnosticReport/ExampleDentalImagingDiagnosticReport
You can also check for usages in the FHIR IG Statistics
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
 Slices for category |
Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
 category:dental |
SΣ | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
  id |
0..1 | string | Unique id for inter-element referencing | |
 extension |
0..* | Extension | Additional content defined by implementations | |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
 id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
 text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
 subject |
SΣ | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist |
 effective[x] |
SΣ | 0..1 | Datum/Zeitraum der Röntgenuntersuchung | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 0..1 | instant | Zeitpunkt der Befunderstellung |
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst |
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden |
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) |
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category:dental | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) |
 status |
S | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown |
| Slices for category |
1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this | |
| category:dental |
S | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Required Pattern: At least the following |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |
| code |
S | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) |
| subject |
S | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist |
| effective[x] |
S | 0..1 | dateTime, Period | Datum/Zeitraum der Röntgenuntersuchung |
| issued |
S | 0..1 | instant | Zeitpunkt der Befunderstellung |
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst |
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden |
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) |
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| Slices for category |
Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:dental |
SΣ | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] |
SΣ | 0..1 | Datum/Zeitraum der Röntgenuntersuchung | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 0..1 | instant | Zeitpunkt der Befunderstellung | ||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden | ||||
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) | ||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) | ||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category:dental | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Structures
This structure refers to these other structures:
- Zahnärztlicher Befund (DE) (https://fhir.cognovis.de/dental/StructureDefinition/dental-finding)
- Zahnärztliche Röntgendiagnostik (DE) (https://fhir.cognovis.de/dental/StructureDefinition/dental-imaging-study)
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of DiagnosticReport.category
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
| Slices for category |
Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| category:dental |
SΣ | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| text |
0..1 | string | Plain text representation of the concept | |
| code |
SΣ | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
| subject |
SΣ | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist |
| effective[x] |
SΣ | 0..1 | Datum/Zeitraum der Röntgenuntersuchung | |
| effectiveDateTime |
dateTime | |||
| effectivePeriod |
Period | |||
| issued |
SΣ | 0..1 | instant | Zeitpunkt der Befunderstellung |
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst |
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden |
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) |
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category:dental | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) |
| status |
S | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown |
| Slices for category |
1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this | |
| category:dental |
S | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |
| code |
S | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) |
| subject |
S | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist |
| effective[x] |
S | 0..1 | dateTime, Period | Datum/Zeitraum der Röntgenuntersuchung |
| issued |
S | 0..1 | instant | Zeitpunkt der Befunderstellung |
| performer |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst |
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden |
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) |
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:reportSubstatus |
S | 0..1 | Coding | Erweiterter Substatus des Befundberichts (praxis: ReportSubstatusCS) URL: https://fhir.cognovis.de/praxis/StructureDefinition/report-substatus Binding: Report Substatus (required) | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn |
0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status |
?!SΣ | 1..1 | code | Status des Befundberichts: registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| Slices for category |
Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:dental |
SΣ | 1..1 | CodeableConcept | Dental-Kategorie (immer 'dental') Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.cognovis.de/dental/CodeSystem/dental-category | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: dental | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Dental | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| code |
SΣ | 1..1 | CodeableConcept | Art der Röntgenuntersuchung (z.B. SNOMED CT oder BEMA-Code) Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Patient, dem die Aufnahme zugeordnet ist | ||||
| encounter |
Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] |
SΣ | 0..1 | Datum/Zeitraum der Röntgenuntersuchung | |||||
| effectiveDateTime |
dateTime | |||||||
| effectivePeriod |
Period | |||||||
| issued |
SΣ | 0..1 | instant | Zeitpunkt der Befunderstellung | ||||
| performer |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Befundender Zahnarzt / Radiologischer Dienst | ||||
| resultsInterpreter |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen |
0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result |
S | 0..* | Reference(Zahnärztlicher Befund (DE)) | Zahnärztliche Einzelbefunde (DentalFindingDE), die aus der Aufnahme abgeleitet wurden | ||||
| imagingStudy |
S | 0..* | Reference(Zahnärztliche Röntgendiagnostik (DE)) | Zugehörige Röntgenaufnahme(n) (DentalImagingStudyDE) | ||||
| media |
Σ | 0..* | BackboneElement | Key images associated with this report | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| comment |
0..1 | string | Comment about the image (e.g. explanation) | |||||
| link |
Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
| conclusion |
S | 0..1 | string | Befundtext (Freitext-Zusammenfassung des Röntgenbefunds) | ||||
| conclusionCode |
0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm |
0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DiagnosticReport.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.status | Base | required | DiagnosticReportStatus | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.category:dental | Base | example | Diagnostic Service Section Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.code | Base | preferred | LOINC Diagnostic Report Codes | 📍4.0.1 | FHIR Std. |
| DiagnosticReport.conclusionCode | Base | example | SNOMED CT Clinical Findings | 📍4.0.1 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements
Must-Support: 11 elements
Structures
This structure refers to these other structures:
- Zahnärztlicher Befund (DE) (https://fhir.cognovis.de/dental/StructureDefinition/dental-finding)
- Zahnärztliche Röntgendiagnostik (DE) (https://fhir.cognovis.de/dental/StructureDefinition/dental-imaging-study)
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of DiagnosticReport.category
Other representations of profile: CSV, Excel, Schematron