This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions
StructureDefinition for Standard Profile for CDA R2 on FHIR
{ "resourceType": "StructureDefinition", "id": "cda-inFulFillmentOf", "meta": { "lastUpdated": "2014-11-05T20:31:00Z" }, "url": "http://hl7.org/fhir/StructureDefinition/cda-inFulFillmentOf", "name": "inFulFillmentOfDiagnosticOrder", "publisher": "HL7 FHIR Project", "contact": [ { "telecom": [ { "system": "url", "value": "http://hl7.org/fhir" } ] } ], "description": "Standard Profile for CDA R2 on FHIR", "status": "draft", "date": "2014-07-28", "mapping": [ { "identity": "cda", "uri": "http://hl7.org/v3/cda", "name": "CDA (R2)" } ], "type": "constraint", "abstract": false, "base": "http://hl7.org/fhir/StructureDefinition/DiagnosticOrder", "snapshot": { "element": [ { "path": "DiagnosticOrder", "short": "CDA inFulFillmentOf", "definition": "A record of a request for a diagnostic investigation service to be performed.", "min": 1, "max": "1", "type": [ { "code": "DomainResource" } ], "mapping": [ { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=RQO, code<\"diagnostic order\"]" }, { "identity": "cda", "map": "inFulFillmentOf" } ] }, { "path": "DiagnosticOrder.id", "short": "Logical id of this artefact", "definition": "The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.", "comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.", "min": 0, "max": "1", "type": [ { "code": "id" } ] }, { "path": "DiagnosticOrder.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min": 0, "max": "1", "type": [ { "code": "Meta" } ] }, { "path": "DiagnosticOrder.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.", "comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.", "min": 0, "max": "1", "type": [ { "code": "uri" } ], "isModifier": true }, { "path": "DiagnosticOrder.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource\n\nNot all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "name": "Language", "strength": "required", "description": "A human language", "valueSetUri": "http://tools.ietf.org/html/bcp47" } }, { "path": "DiagnosticOrder.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "path": "DiagnosticOrder.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.subject", "short": "Populate from the Composition subject", "definition": "Who or what the investigation is to be performed on. This is usually a human patient, but diagnostic tests can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans).", "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Patient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Group" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Location" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SBJ].role" }, { "identity": "cda", "map": "../recordTarget..." } ] }, { "path": "DiagnosticOrder.orderer", "short": "Who ordered the test", "definition": "The practitioner that holds legal responsibility for ordering the investigation.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".participation[typeCode=AUT].role" } ] }, { "path": "DiagnosticOrder.identifier", "short": "Identifiers assigned to this order", "definition": "Identifiers assigned to this order by the order or by the receiver.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".id" }, { "identity": "cda", "map": ".order.id" } ] }, { "path": "DiagnosticOrder.encounter", "short": "The encounter that this diagnostic order is associated with", "definition": "An encounter that provides additional information about the healthcare context in which this request is made.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Encounter" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]" } ] }, { "path": "DiagnosticOrder.clinicalNotes", "short": "Explanation/Justification for test", "definition": "An explanation or justification for why this diagnostic investigation is being requested.", "comments": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "rim", "map": ".reasonCode.originalText" } ] }, { "path": "DiagnosticOrder.supportingInformation", "short": "Additional clinical information", "definition": "Additional clinical information about the patient or specimen that may influence test interpretations.", "comments": "This information includes diagnosis, clinical findings and other observations. Examples include reporting the amount of inspired carbon dioxide for blood gasses, the point in the menstrual cycle for cervical pap tests, and other conditions that influence test interpretations.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Observation" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Condition" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/DocumentReference" } ], "mapping": [ { "identity": "v2", "map": "OBR-13" }, { "identity": "rim", "map": "outboundRelationship[typeCode=SPRT]/target[classCode=ACT, moodCode=EVN]" } ] }, { "path": "DiagnosticOrder.specimen", "short": "If the whole order relates to specific specimens", "definition": "One or more specimens that the diagnostic investigation is about.", "comments": "Many investigation requests will create a need for specimens, but the request itself is not actually about the specimens. This is provided for when the diagnostic investigation is requested on already existing specimens.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SPC].role" } ] }, { "path": "DiagnosticOrder.status", "short": "proposed | draft | planned | requested | received | accepted | in-progress | review | completed | cancelled | suspended | rejected | failed", "definition": "The status of the order.", "comments": "Typically the system placing the order sets the status to requested. Thereafter, the order is maintained by the receiver that updates the status as the request is handled.", "min": 0, "max": "1", "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "name": "DiagnosticOrderStatus", "strength": "required", "description": "The status of a diagnostic order", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode\ralso influenced by whether a ControlAct fulfillment requeste exists, whether a promise exists, status of the review component, whether a fulfilling observation exists, whether a refusal exists" } ] }, { "path": "DiagnosticOrder.priority", "short": "routine | urgent | stat | asap", "definition": "The clinical priority associated with this order.", "comments": "The Order resource also has a priority. Generally, these should be the same, but they can be different, for instance in the case where the clinician indicates that the order is urgent, but the subsequent workflow process overrule this priority for some reason. The effective default value is \"normal\".", "min": 0, "max": "1", "type": [ { "code": "code" } ], "isSummary": true, "binding": { "name": "DiagnosticOrderPriority", "strength": "required", "description": "The clinical priority of a diagnostic order", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-order-priority" } }, "mapping": [ { "identity": "rim", "map": ".priorityCode" }, { "identity": "cda", "map": ".inFulfillment/Order/priorityCode" } ] }, { "path": "DiagnosticOrder.event", "name": "event", "short": "A list of events of interest in the lifecycle", "definition": "A summary of the events of interest that have occurred as the request is processed. E.g. when the order was made, various processing steps (specimens received), when it was completed.", "comments": "This is not the same as an audit trail - it is a view of the important things that happened in the past. Typically, there would only be one entry for any given status, and systems may not record all the status events.", "min": 0, "max": "*", "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=FLFS].source" } ] }, { "path": "DiagnosticOrder.event.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "DiagnosticOrder.event.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "DiagnosticOrder.event.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.event.status", "short": "proposed | draft | planned | requested | received | accepted | in-progress | review | completed | cancelled | suspended | rejected | failed", "definition": "The status for the event.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "isSummary": true, "binding": { "name": "DiagnosticOrderStatus", "strength": "required", "description": "The status of a diagnostic order", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode\ralso influenced by whether a ControlAct fulfillment requeste exists, whether a promise exists, status of the review component, whether a fulfilling observation exists, whether a refusal exists" } ] }, { "path": "DiagnosticOrder.event.description", "short": "More information about the event and its context", "definition": "Additional information about the event that occurred - e.g. if the status remained unchanged.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "name": "DiagnosticOrderEventDescription", "strength": "example", "description": "Additional information about an event that occurred to a diagnostic order - e.g. if the status remained unchanged", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-order-event" } }, "mapping": [ { "identity": "rim", "map": ".text" } ] }, { "path": "DiagnosticOrder.event.dateTime", "short": "The date at which the event happened", "definition": "The date/time at which the event occurred.", "min": 1, "max": "1", "type": [ { "code": "dateTime" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".effectiveTime" } ] }, { "path": "DiagnosticOrder.event.actor", "short": "Who recorded or did this", "definition": "The person who was responsible for performing or recording the action.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Practitioner" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Device" } ], "mapping": [ { "identity": "rim", "map": ".participation[AUT or PFM]" } ] }, { "path": "DiagnosticOrder.item", "short": "The items the orderer requested", "definition": "The specific diagnostic investigations that are requested as part of this request. Sometimes, there can only be one item per request, but in most contexts, more than one investigation can be requested.", "comments": "There would always be at least one item in normal usage, but this is optional so that a workflow can quote order details without having to list the items.", "min": 0, "max": "1", "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=OBS, moodCode=OBS]" }, { "identity": "cda", "map": ".order.code" } ] }, { "path": "DiagnosticOrder.item.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "DiagnosticOrder.item.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "DiagnosticOrder.item.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.item.code", "short": "CDA ORder Code", "definition": "A code that identifies a particular diagnostic investigation, or panel of investigations, that have been requested.", "comments": "Many laboratory tests and radiology tests embed the specimen/organ system in the test name, for example, serum or serum/plasma glucose, or a chest xray. The specimen may not be recorded separately from the test code.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "name": "DiagnosticRequests", "strength": "required", "description": "Codes for tests/services that can be performed by diagnostic services", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-requests" } }, "mapping": [ { "identity": "v2", "map": "OBX-4" }, { "identity": "rim", "map": ".code" }, { "identity": "cda", "map": ".order.code" } ] }, { "path": "DiagnosticOrder.item.specimen", "short": "If this item relates to specific specimens", "definition": "If the item is related to a specific specimen.", "comments": "A single specimen should not appear in both DiagnosticOrder.specimen and DiagnosticOrder.item.specimen.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/Specimen" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SPC].role" } ] }, { "path": "DiagnosticOrder.item.bodySite[x]", "short": "Location of requested test (if applicable)", "definition": "Anatomical location where the request test should be performed. This is the target site.", "alias": [ "location" ], "min": 0, "max": "0", "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "profile": "http://hl7.org/fhir/StructureDefinition/BodySite" } ], "binding": { "name": "BodySite", "strength": "example", "description": "Codes describing anatomical locations. May include laterality", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/body-site" } }, "mapping": [ { "identity": "rim", "map": "targetSiteCode" } ] }, { "path": "DiagnosticOrder.item.status", "short": "proposed | draft | planned | requested | received | accepted | in-progress | review | completed | cancelled | suspended | rejected | failed", "definition": "The status of this individual item within the order.", "comments": "If the request has multiple items that have their own life cycles, then the items will have their own status while the overall diagnostic order is (usually) \"in-progress\".", "min": 0, "max": "1", "type": [ { "code": "code" } ], "isSummary": true, "binding": { "name": "DiagnosticOrderStatus", "strength": "required", "description": "The status of a diagnostic order", "valueSetReference": { "reference": "http://hl7.org/fhir/vs/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode\ralso influenced by whether a ControlAct fulfillment requeste exists, whether a promise exists, status of the review component, whether a fulfilling observation exists, whether a refusal exists" } ] }, { "path": "DiagnosticOrder.item.event", "short": "Events specific to this item", "definition": "A summary of the events of interest that have occurred as this item of the request is processed.", "min": 0, "max": "*", "nameReference": "event", "isSummary": true, "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=FLFS].source" } ] } ] }, "differential": { "element": [ { "path": "DiagnosticOrder", "short": "CDA inFulFillmentOf", "min": 1, "max": "1", "isModifier": false, "mapping": [ { "identity": "cda", "map": "inFulFillmentOf" } ] }, { "path": "DiagnosticOrder.subject", "short": "Populate from the Composition subject", "isModifier": false, "mapping": [ { "identity": "cda", "map": "../recordTarget..." } ] }, { "path": "DiagnosticOrder.orderer[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.identifier", "short": "Identifiers assigned to this order", "definition": "Identifiers assigned to this order by the order or by the receiver.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "isModifier": false, "mapping": [ { "identity": "cda", "map": ".order.id" } ] }, { "path": "DiagnosticOrder.encounter[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.clinicalNotes[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.supportingInformation[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.specimen[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.status[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.priority", "mapping": [ { "identity": "cda", "map": ".inFulfillment/Order/priorityCode" } ] }, { "path": "DiagnosticOrder.event[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.item", "min": 0, "max": "1", "isModifier": false, "mapping": [ { "identity": "cda", "map": ".order.code" } ] }, { "path": "DiagnosticOrder.item.code", "short": "CDA ORder Code", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "isModifier": false, "mapping": [ { "identity": "cda", "map": ".order.code" } ] }, { "path": "DiagnosticOrder.item.specimen[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.item.bodySite[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.item.status[x]", "min": 0, "max": "0", "isModifier": true }, { "path": "DiagnosticOrder.item.event[x]", "min": 0, "max": "0", "isModifier": true } ] } }