@prefix fhir: . @prefix loinc: . @prefix owl: . @prefix rdfs: . @prefix sct: . @prefix xsd: . # - resource ------------------------------------------------------------------- a fhir:Bundle ; fhir:nodeRole fhir:treeRoot ; fhir:Resource.id [ fhir:value "TransurethralEnucleationDocument"] ; fhir:Bundle.identifier [ fhir:Identifier.system [ fhir:value "https://pathologie.example-hospital.de/fhir/fn/befundbericht" ] ; fhir:Identifier.value [ fhir:value "E_24_004" ] ] ; fhir:Bundle.type [ fhir:value "document"] ; fhir:Bundle.timestamp [ fhir:value "2024-04-15T08:00:00+01:00"^^xsd:dateTime] ; fhir:Bundle.entry [ fhir:index 0 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Composition/TransurethralEnucleationComposition" ] ; fhir:Bundle.entry.resource ], [ fhir:index 1 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Patient/Patient3" ] ; fhir:Bundle.entry.resource ], [ fhir:index 2 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Organization/PathologyLabOrganization" ] ; fhir:Bundle.entry.resource ], [ fhir:index 3 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/DiagnosticReport/TransurethralEnucleationReport" ] ; fhir:Bundle.entry.resource ], [ fhir:index 4 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Observation/TransurethralEnucleationDiagnosticConclusionGrouper" ] ; fhir:Bundle.entry.resource ], [ fhir:index 5 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Observation/TransurethralEnucleationMacroscopicGrouper" ] ; fhir:Bundle.entry.resource ], [ fhir:index 6 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/Encounter/TransurethralEnucleationEncounter" ] ; fhir:Bundle.entry.resource ], [ fhir:index 7 ; fhir:Bundle.entry.fullUrl [ fhir:value "http://prostatecancerspec.org/ServiceRequest/TransurethralEnucleationReportRequest" ] ; fhir:Bundle.entry.resource ] . a fhir:Composition ; fhir:Resource.id [ fhir:value "TransurethralEnucleationComposition"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Composition TransurethralEnucleationComposition

identifier: Accession ID/PATH-COMP-2024-004

status: Final

type: Pathology study

encounter: Encounter: identifier = http://example.hospital.de/encounters#E_24_004; status = finished; class = IMP (IMP)

date: 2024-04-15 08:00:00+0100

author: Pathologisches Institut

title: Histopathologischer Befundbericht - Prostata Enucleation

Attesters

-ModeParty
*LegalOrganization Pathologielabor

custodian: Organization Pathologielabor

Events

-CodeDetail
*pathology report entry taskServiceRequest Prostatectomy (procedure)
" ] ; fhir:Composition.identifier [ fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ACSN" ] ; fhir:Coding.display [ fhir:value "Accession ID" ] ] ] ; fhir:Identifier.system [ fhir:value "http://example.hospital.de/pathology-reports" ] ; fhir:Identifier.value [ fhir:value "PATH-COMP-2024-004" ] ] ; fhir:Composition.status [ fhir:value "final"] ; fhir:Composition.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; a loinc:11526-1 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "11526-1" ] ; fhir:Coding.display [ fhir:value "Pathology study" ] ], [ fhir:index 1 ; fhir:Coding.system [ fhir:value "http://ihe-d.de/CodeSystems/IHEXDStypeCode" ] ; fhir:Coding.code [ fhir:value "PATH" ] ] ] ; fhir:Composition.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ; fhir:Reference.display [ fhir:value "Klaus Becker, geb. 10.11.1958 (PAT-2024-003)" ] ] ; fhir:Composition.encounter [ fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/TransurethralEnucleationEncounter" ] ] ; fhir:Composition.date [ fhir:value "2024-04-15T08:00:00+01:00"^^xsd:dateTime] ; fhir:Composition.author [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ] ; fhir:Reference.display [ fhir:value "Pathologisches Institut" ] ] ; fhir:Composition.title [ fhir:value "Histopathologischer Befundbericht - Prostata Enucleation"] ; fhir:Composition.attester [ fhir:index 0 ; fhir:Composition.attester.mode [ fhir:value "legal" ] ; fhir:Composition.attester.party [ fhir:link ; fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ] ] ] ; fhir:Composition.custodian [ fhir:link ; fhir:Reference.reference [ fhir:value "Organization/PathologyLabOrganization" ] ] ; fhir:Composition.event [ fhir:index 0 ; fhir:Composition.event.code [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v3-ActCode" ] ; fhir:Coding.code [ fhir:value "PATREPE" ] ] ] ; fhir:Composition.event.detail [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "ServiceRequest/TransurethralEnucleationReportRequest" ] ] ] ; fhir:Composition.section [ fhir:index 0 ; fhir:Composition.section.title [ fhir:value "Pathologiebefundbericht" ] ; fhir:Composition.section.code [ fhir:CodeableConcept.coding [ fhir:index 0 ; a loinc:60567-5 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "60567-5" ] ; fhir:Coding.display [ fhir:value "Comprehensive pathology report panel" ] ] ] ; fhir:Composition.section.text [ fhir:Narrative.status [ fhir:value "additional" ] ; fhir:Narrative.div "

Klinische Angaben

Obstruktive Miktionsbeschwerden. PSA 12,5 ng/ml. Prostata-Enukleation (HoLEP/ThuLEP). V.a. Prostatakarzinom.

Makroskopie

Enukleationspräparat 25 g, Maße 3,5 × 2,8 × 2,2 cm. Keine Samenblasen, keine Lymphknoten im Resektat.

PräparatProstata-Enukleationspräparat
Gewicht25 g
Maße (L × B × T)3,5 × 2,8 × 2,2 cm
SamenblasenNicht im Resektat
LymphknotenNicht im Resektat

Mikroskopie

Azinäres Adenokarzinom der Prostata mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration mit perineuralem und lymphovaskulärem Befall.

Diagnostische Schlussfolgerung

Gleason-Score 4+5=9, ISUP-Gradgruppe 5 (WHO 2016). Anteil Gleasonmuster 4/5: 90%. Tumorinfiltration ca. 60% des Prostatagewebes. Intraduktales Karzinom und invasive kribriforme Anteile nachgewiesen. Extraprostatische Ausbreitung, Samenblaseninvasion, lymphovaskuläre Invasion und perineurale Infiltration nachgewiesen.

Histologischer TypAzinäres Adenokarzinom mit invasiven kribriformen Anteilen (8140/3)
Gleason-Score4+5=9
ISUP-Gradgruppe5 (WHO 2016)
Tumoranteil60%
Anteil Gleason 4/590%
Intraduktales KarzinomNachgewiesen
Invasives kribriformes KarzinomNachgewiesen
Extraprostatische AusbreitungNachgewiesen
SamenblaseninfiltrationNachgewiesen
Lymphovaskuläre InvasionNachgewiesen
Perineurale InfiltrationNachgewiesen

Diagnose: Azinäres Adenokarzinom der Prostata (ICD-O 8140/3) – High-grade

Empfehlung: Staging-Untersuchungen und interdisziplinäre Tumorkonferenz.

" ] ; fhir:Composition.section.entry [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "DiagnosticReport/TransurethralEnucleationReport" ] ] ] . a fhir:Patient ; fhir:Resource.id [ fhir:value "Patient3"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Patient Patient3

Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)

" ] ; fhir:Patient.identifier [ fhir:index 0 ; fhir:Identifier.system [ fhir:value "http://example.hospital.de/patient-ids" ] ; fhir:Identifier.value [ fhir:value "PAT-2024-003" ] ] ; fhir:Patient.name [ fhir:index 0 ; fhir:HumanName.family [ fhir:value "Becker" ] ; fhir:HumanName.given [ fhir:value "Klaus" ; fhir:index 0 ] ] ; fhir:Patient.gender [ fhir:value "male"] ; fhir:Patient.birthDate [ fhir:value "1958-11-10"^^xsd:date] . a fhir:Organization ; fhir:Resource.id [ fhir:value "PathologyLabOrganization"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Organization PathologyLabOrganization

identifier: http://example.hospital.de/organization-ids/ORG-PATH-001

name: Pathologielabor

" ] ; fhir:Organization.identifier [ fhir:index 0 ; fhir:Identifier.system [ fhir:value "http://example.hospital.de/organization-ids" ] ; fhir:Identifier.value [ fhir:value "ORG-PATH-001" ] ] ; fhir:Organization.name [ fhir:value "Pathologielabor"] . a fhir:DiagnosticReport ; fhir:Resource.id [ fhir:value "TransurethralEnucleationReport"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-report|2026.0.0" ; fhir:index 0 ; fhir:link ] ] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: DiagnosticReport TransurethralEnucleationReport

Profile: MII PR Patho Report version: 2026.0.0

Pathology Synoptic report (Surgical Pathology)

SubjectKlaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)
Relevant Time2024-05-12 17:00:00+0100
Reported2024-05-13 08:00:00+0100
Performer Practitioner Maria Schneider
Identifier Accession ID/E_24_004

Report Details

CodeValueFlagsRelevant Time
Pathology report gross observation Narrative (Prostate)Final2024-04-11 14:00:00+0100
Pathology report final diagnosis NarrativeFinal2024-05-12

Prostata Enucleation: Azinäres Adenokarzinom, Gleason Score 4+5=9 (ISUP Grade Group 5), mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration (60% des Gewebes) mit extraprostatischer Extension, Samenblaseninvasion, perineuralem und lymphovaskulärem Befall.

" ] ; fhir:DiagnosticReport.identifier [ fhir:index 0 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "ACSN" ] ; fhir:Coding.display [ fhir:value "Accession ID" ] ] ] ; fhir:Identifier.system [ fhir:value "https://pathologie.example-hospital.de/fhir/fn/befundbericht" ] ; fhir:Identifier.value [ fhir:value "E_24_004" ] ] ; fhir:DiagnosticReport.basedOn [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "ServiceRequest/TransurethralEnucleationReportRequest" ] ] ; fhir:DiagnosticReport.status [ fhir:value "final"] ; fhir:DiagnosticReport.category [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0074" ] ; fhir:Coding.code [ fhir:value "SP" ] ; fhir:Coding.display [ fhir:value "Surgical Pathology" ] ] ] ; fhir:DiagnosticReport.code [ fhir:CodeableConcept.coding [ fhir:index 0 ; a loinc:60568-3 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "60568-3" ] ; fhir:Coding.display [ fhir:value "Pathology Synoptic report" ] ] ] ; fhir:DiagnosticReport.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ] ; fhir:DiagnosticReport.effectiveDateTime [ fhir:value "2024-05-12T17:00:00+01:00"^^xsd:dateTime] ; fhir:DiagnosticReport.issued [ fhir:value "2024-05-13T08:00:00+01:00"^^xsd:dateTime] ; fhir:DiagnosticReport.performer [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/PathologistPractitioner" ] ] ; fhir:DiagnosticReport.specimen [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenPart" ] ], [ fhir:index 1 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenBlock01" ] ], [ fhir:index 2 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide01A" ] ], [ fhir:index 3 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide01B" ] ], [ fhir:index 4 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenBlock02" ] ], [ fhir:index 5 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide02A" ] ], [ fhir:index 6 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide02B" ] ], [ fhir:index 7 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenBlock03" ] ], [ fhir:index 8 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide03A" ] ], [ fhir:index 9 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide03B" ] ], [ fhir:index 10 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenBlock04" ] ], [ fhir:index 11 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide04A" ] ], [ fhir:index 12 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide04B" ] ], [ fhir:index 13 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenBlock05" ] ], [ fhir:index 14 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide05A" ] ], [ fhir:index 15 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenSlide05B" ] ] ; fhir:DiagnosticReport.result [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicGrouper" ] ], [ fhir:index 1 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationDiagnosticConclusionGrouper" ] ] ; fhir:DiagnosticReport.conclusion [ fhir:value "Prostata Enucleation: Azinäres Adenokarzinom, Gleason Score 4+5=9 (ISUP Grade Group 5), mit invasiven cribriformen Anteilen und intraduktalem Karzinom. Extensive Tumorinfiltration (60% des Gewebes) mit extraprostatischer Extension, Samenblaseninvasion, perineuralem und lymphovaskulärem Befall."] . a fhir:Observation ; fhir:Resource.id [ fhir:value "TransurethralEnucleationDiagnosticConclusionGrouper"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-diagnostic-conclusion-grouper|2026.0.0" ; fhir:index 0 ; fhir:link ] ] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Observation TransurethralEnucleationDiagnosticConclusionGrouper

basedOn: ServiceRequest Prostatectomy (procedure)

status: Final

category: Laboratory

code: Pathology report final diagnosis Narrative

subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)

effective: 2024-05-12

performer: Practitioner Maria Schneider

hasMember:

derivedFrom: Response to Questionnaire 'https://art-decor.org/fhir/Questionnaire/2.16.840.1.113883.3.1937.777.18.27.22--20251014150033' about '->Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)'

" ] ; fhir:Observation.basedOn [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "ServiceRequest/TransurethralEnucleationReportRequest" ] ] ; fhir:Observation.status [ fhir:value "final"] ; fhir:Observation.category [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/observation-category" ] ; fhir:Coding.code [ fhir:value "laboratory" ] ] ] ; fhir:Observation.code [ fhir:CodeableConcept.coding [ fhir:index 0 ; a loinc:22637-3 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "22637-3" ] ] ] ; fhir:Observation.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ] ; fhir:Observation.effectiveDateTime [ fhir:value "2024-05-12"^^xsd:date] ; fhir:Observation.performer [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/PathologistPractitioner" ] ] ; fhir:Observation.hasMember [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationHistologicalTypeICDO3" ] ], [ fhir:index 1 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMorphologyFreeText" ] ], [ fhir:index 2 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationPrimaryGleasonPattern" ] ], [ fhir:index 3 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationSecondaryGleasonPattern" ] ], [ fhir:index 4 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationGleasonScoreTotal" ] ], [ fhir:index 5 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationPercentageGleason45" ] ], [ fhir:index 6 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationGradingGroupISUP" ] ], [ fhir:index 7 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationIntraductalCarcinoma" ] ], [ fhir:index 8 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationInvasiveCribriformCarcinoma" ] ], [ fhir:index 9 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationProstaticTissueInvolved" ] ], [ fhir:index 10 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationExtraprostaticExtension" ] ], [ fhir:index 11 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationSeminalVesicleInvasion" ] ], [ fhir:index 12 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationLymphovascularInvasion" ] ], [ fhir:index 13 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationPerineuralInfiltration" ] ] ; fhir:Observation.derivedFrom [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "QuestionnaireResponse/QuestionnaireResponseTransurethralEnucleation" ] ] . a fhir:Observation ; fhir:Resource.id [ fhir:value "TransurethralEnucleationMacroscopicGrouper"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-macroscopic-grouper|2026.0.0" ; fhir:index 0 ; fhir:link ] ] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Observation TransurethralEnucleationMacroscopicGrouper

Profile: MII PR Patho Macroscopic Grouper version: 2026.0.0

status: Final

category: Laboratory

code: Pathology report gross observation Narrative

subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)

effective: 2024-04-11 14:00:00+0100

performer: Practitioner Maria Schneider

bodySite: Prostate

hasMember:

derivedFrom: Response to Questionnaire 'https://art-decor.org/fhir/Questionnaire/2.16.840.1.113883.3.1937.777.18.27.22--20251014150033' about '->Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)'

" ] ; fhir:Observation.status [ fhir:value "final"] ; fhir:Observation.category [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/observation-category" ] ; fhir:Coding.code [ fhir:value "laboratory" ] ] ] ; fhir:Observation.code [ fhir:CodeableConcept.coding [ fhir:index 0 ; a loinc:22634-0 ; fhir:Coding.system [ fhir:value "http://loinc.org" ] ; fhir:Coding.code [ fhir:value "22634-0" ] ] ] ; fhir:Observation.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ] ; fhir:Observation.effectiveDateTime [ fhir:value "2024-04-11T14:00:00+01:00"^^xsd:dateTime] ; fhir:Observation.performer [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/PathologistPractitioner" ] ] ; fhir:Observation.bodySite [ fhir:CodeableConcept.coding [ fhir:index 0 ; a sct:41216001 ; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ; fhir:Coding.code [ fhir:value "41216001" ] ; fhir:Coding.display [ fhir:value "Prostate" ] ] ] ; fhir:Observation.hasMember [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicWeight" ] ], [ fhir:index 1 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicLength" ] ], [ fhir:index 2 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicWidth" ] ], [ fhir:index 3 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicDepth" ] ], [ fhir:index 4 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicSeminalVesicles" ] ], [ fhir:index 5 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationMacroscopicLymphNodeDissection" ] ] ; fhir:Observation.derivedFrom [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "QuestionnaireResponse/QuestionnaireResponseTransurethralEnucleation" ] ] . a fhir:Encounter ; fhir:Resource.id [ fhir:value "TransurethralEnucleationEncounter"] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: Encounter TransurethralEnucleationEncounter

identifier: http://example.hospital.de/encounters/E_24_004

status: Finished

class: [not stated]: IMP (IMP)

subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)

" ] ; fhir:Encounter.identifier [ fhir:index 0 ; fhir:Identifier.system [ fhir:value "http://example.hospital.de/encounters" ] ; fhir:Identifier.value [ fhir:value "E_24_004" ] ] ; fhir:Encounter.status [ fhir:value "finished"] ; fhir:Encounter.class [ fhir:Coding.code [ fhir:value "IMP" ] ] ; fhir:Encounter.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ] . a fhir:ServiceRequest ; fhir:Resource.id [ fhir:value "TransurethralEnucleationReportRequest"] ; fhir:Resource.meta [ fhir:Meta.profile [ fhir:value "https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-service-request|2026.0.0" ; fhir:index 0 ; fhir:link ] ] ; fhir:DomainResource.text [ fhir:Narrative.status [ fhir:value "generated" ] ; fhir:Narrative.div "

Generated Narrative: ServiceRequest TransurethralEnucleationReportRequest

Profile: MII PR Patho Service Request version: 2026.0.0

identifier: Placer Identifier/PATH-RPT-2024-004

status: Completed

intent: Order

category: Pathology consultation, comprehensive, records and specimen with report (procedure)

code: Prostatectomy (procedure)

subject: Klaus Becker Male, DoB: 1958-11-10 ( http://example.hospital.de/patient-ids#PAT-2024-003)

encounter: Encounter: identifier = http://example.hospital.de/encounters#E_24_004; status = finished; class = IMP (IMP)

requester: Practitioner Andreas Weber

performer: Practitioner Maria Schneider

reasonCode: Benign prostatic hyperplasia

supportingInfo:

specimen: Specimen: identifier = Placer Identifier,Filler Identifier; accessionIdentifier = https://pathologie.example-hospital.de/fhir/fn/befundbericht#E_24_004; status = available; type = Tissue specimen

" ] ; fhir:ServiceRequest.identifier [ fhir:index 0 ; fhir:Identifier.type [ fhir:CodeableConcept.coding [ fhir:index 0 ; fhir:Coding.system [ fhir:value "http://terminology.hl7.org/CodeSystem/v2-0203" ] ; fhir:Coding.code [ fhir:value "PLAC" ] ; fhir:Coding.display [ fhir:value "Placer Identifier" ] ] ] ; fhir:Identifier.system [ fhir:value "http://example.hospital.de/serviceRequest" ] ; fhir:Identifier.value [ fhir:value "PATH-RPT-2024-004" ] ] ; fhir:ServiceRequest.status [ fhir:value "completed"] ; fhir:ServiceRequest.intent [ fhir:value "order"] ; fhir:ServiceRequest.category [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; a sct:726007 ; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ; fhir:Coding.code [ fhir:value "726007" ] ; fhir:Coding.display [ fhir:value "Pathology consultation, comprehensive, records and specimen with report (procedure)" ] ] ] ; fhir:ServiceRequest.code [ fhir:CodeableConcept.coding [ fhir:index 0 ; a sct:90470006 ; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ; fhir:Coding.code [ fhir:value "90470006" ] ; fhir:Coding.display [ fhir:value "Prostatectomy (procedure)" ] ] ] ; fhir:ServiceRequest.subject [ fhir:link ; fhir:Reference.reference [ fhir:value "Patient/Patient3" ] ] ; fhir:ServiceRequest.encounter [ fhir:link ; fhir:Reference.reference [ fhir:value "Encounter/TransurethralEnucleationEncounter" ] ] ; fhir:ServiceRequest.requester [ fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/UrologistPractitioner" ] ] ; fhir:ServiceRequest.performer [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Practitioner/PathologistPractitioner" ] ] ; fhir:ServiceRequest.reasonCode [ fhir:index 0 ; fhir:CodeableConcept.coding [ fhir:index 0 ; a sct:266569009 ; fhir:Coding.system [ fhir:value "http://snomed.info/sct" ] ; fhir:Coding.code [ fhir:value "266569009" ] ; fhir:Coding.display [ fhir:value "Benign prostatic hyperplasia" ] ] ] ; fhir:ServiceRequest.supportingInfo [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Observation/TransurethralEnucleationPSAPre" ] ], [ fhir:index 1 ; fhir:link ; fhir:Reference.reference [ fhir:value "Procedure/TransurethralEnucleationProcedure" ] ], [ fhir:index 2 ; fhir:link ; fhir:Reference.reference [ fhir:value "Condition/TransurethralEnucleationDiagnosisBPH" ] ] ; fhir:ServiceRequest.specimen [ fhir:index 0 ; fhir:link ; fhir:Reference.reference [ fhir:value "Specimen/TransurethralEnucleationSpecimenPart" ] ] . # - ontology header ------------------------------------------------------------ a owl:Ontology ; owl:imports fhir:fhir.ttl . # -------------------------------------------------------------------------------------