DSTU2 QA Preview

This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

F.??.4 StructureDefinition: QICore-Specimen - Detailed Descriptions

Definitions for the qicore-specimen Profile.

Specimen(QICore-Specimen)
Definition

Sample for analysis.

Control0..*
TypeSpecimen
Specimen.id
Definition

The logical id of the resource, as used in the url for the resource. Once assigned, this value never changes.

Control0..1
Typeid
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.

Specimen.meta
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.

Control0..1
TypeMeta
Specimen.implicitRules
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.

Control0..1
Typeuri
Is Modifiertrue
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.

Specimen.language
Definition

The base language in which the resource is written.

Control0..1
BindingA human language
The codes SHALL be taken from http://tools.ietf.org/html/bcp47
Typecode
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 Not 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).

Specimen.text
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.

Control0..1 This element is affected by the following invariants: dom-1
TypeNarrative
Alternate Namesnarrative, html, xhtml, display
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.

Specimen.contained
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.

Control0..*
TypeResource
Alternate Namesinline resources, anonymous resources, contained resources
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.

Specimen.extension
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.

Control0..*
TypeExtension
Alternate Namesextensions, user content
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.

Specimen.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content
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.

Specimen.identifier
Definition

Id for specimen.

Control0..*
TypeIdentifier
Specimen.status
Definition

The availability of the specimen.

Control0..1
BindingCodes providing the status/availability of a specimen
The codes SHALL be taken from SpecimenStatus
Typecode
Is Modifiertrue
Specimen.type
Definition

The kind of material that forms the specimen.

Control0..1
BindingThe type of the specimen.
For example codes, see v2 Specimen Type
TypeCodeableConcept
Must Supporttrue
Comments

The type can change the way that a specimen is handled, and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems.

Specimen.parent
Definition

Reference to the parent (source) specimen which is used when the specimen was either derived from or a component of a another specimen.

Control0..*
TypeReference(QICore-Specimen)
Comments

The parent specimen could be the source from which the current specimen is derived by some processing step (e.g.  an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample.

Specimen.subject
Definition

Where the specimen came from. This may be from the patient(s) or from the environment or a device.

Control1..1
TypeChoice of: Reference(QICore-Patient), Reference(QICore-Device), Reference(QICore-Substance), Reference(Group)
Must Supporttrue
Requirements

Must know the subject context.

Specimen.accessionIdentifier
Definition

The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.

Control0..1
TypeIdentifier
Specimen.receivedTime
Definition

Time when specimen was received for processing or testing.

Control0..1
TypedateTime
Must Supporttrue
Specimen.collection
Definition

Details concerning the specimen collection.

Control0..1
TypeBackboneElement
Specimen.collection.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Specimen.collection.extension (http://hl7.org/fhir/StructureDefinition/specimen-specialHandling)
Definition

Special handling during the collection, transport, or storage of the specimen.

Control0..*
TypeExtension (Extension Type: CodeableConcept)
Specimen.collection.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
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.

Specimen.collection.collector
Definition

Person who collected the specimen.

Control0..1
TypeReference(QICore-Practitioner)
Specimen.collection.comment
Definition

To communicate any details or issues encountered during the specimen collection procedure.

Control0..*
Typestring
Specimen.collection.collected[x]
Definition

Time when specimen was collected from subject - the physiologically relevant time.

Control0..1
TypeChoice of: dateTime, Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Must Supporttrue
Specimen.collection.quantity
Definition

The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample.

Control0..1
TypeQuantity(SimpleQuantity)
Specimen.collection.quantity.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Specimen.collection.quantity.extension (http://hl7.org/fhir/StructureDefinition/specimen-isDryWeight)
Definition

If the recorded quantity of the specimen is reported as a weight, if it is a dry weight.

Control0..1
TypeExtension (Extension Type: boolean)
Specimen.collection.quantity.value
Definition

The value of the measured amount. The value includes an implicit precision in the presentation of the value.

Control0..1
Typedecimal
Requirements

Precision is handled implicitly in almost all cases of measurement.

Comments

The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

Specimen.collection.quantity.comparator
Definition

How the value should be understood and represented - whether the actual value is greater or less than the stated value due to measurement issues. E.g. if the comparator is "<" , then the real value is < stated value.

Control0..1
BindingHow the Quantity should be understood and represented
The codes SHALL be taken from QuantityComparator
Typecode
Is Modifiertrue
Requirements

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

Comments

This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value.

Meaning if MissingIf there is no comparator, then there is no modification of the value
Specimen.collection.quantity.unit
Definition

A human-readable form of the units.

Control0..1
Typestring
Requirements

There are many representations for units and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

Specimen.collection.quantity.system
Definition

The identification of the system that provides the coded form of the unit.

Control0..1 This element is affected by the following invariants: qty-3
Typeuri
Requirements

Need to know the system that defines the coded form of the unit.

Specimen.collection.quantity.code
Definition

A computer processable form of the units in some unit representation system.

Control0..1
Typecode
Requirements

Need a computable form of the units that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.

Comments

The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.

Specimen.collection.method
Definition

A coded value specifying the technique that is used to perform the procedure.

Control0..1
BindingThe technique that is used to perform the procedure
For example codes, see SpecimenCollectionMethod
TypeCodeableConcept
Specimen.collection.bodySite
Definition

Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens.

Control0..1
BindingCodes describing anatomical locations. May include laterality
For example codes, see SNOMED CT Body Structures
TypeCodeableConcept
Must Supporttrue
Comments

If the use case requires BodySite to be be handled as a separate resource instead of an inline coded element ( e.g. to identify and track separately) then use the standard extension body-site-instance.

Specimen.treatment
Definition

Details concerning treatment and processing steps for the specimen.

Control0..*
TypeBackboneElement
Specimen.treatment.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Specimen.treatment.extension (http://hl7.org/fhir/StructureDefinition/specimen-treatmentTime)
Definition

Period or duration of treatment.

Control0..1
TypeExtension (Extension Type: Choice of: Period, Quantity(Duration))
Specimen.treatment.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
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.

Specimen.treatment.description
Definition

Textual description of procedure.

Control0..1
Typestring
Specimen.treatment.procedure
Definition

A coded value specifying the procedure used to process the specimen.

Control0..1
BindingType indicating the technique used to process the specimen
For example codes, see SpecimenTreatmentProcedure
TypeCodeableConcept
Must Supporttrue
Specimen.treatment.additive
Definition

Material used in the processing step.

Control0..*
TypeReference(QICore-Substance)
Specimen.container
Definition

The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.

Control0..*
TypeBackboneElement
Specimen.container.id
Definition

unique id for the element within a resource (for internal references).

Control0..1
Typeid
Specimen.container.extension (http://hl7.org/fhir/StructureDefinition/specimen-sequenceNumber)
Definition

An assigned number on the specimen denoting the order of collection.

Control0..1
TypeExtension (Extension Type: integer)
Specimen.container.modifierExtension
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.

Control0..*
TypeExtension
Is Modifiertrue
Alternate Namesextensions, user content, modifiers
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.

Specimen.container.identifier
Definition

Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.

Control0..*
TypeIdentifier
Specimen.container.description
Definition

Textual description of the container.

Control0..1
Typestring
Specimen.container.type
Definition

The type of container associated with the specimen (e.g. slide, aliquot, etc).

Control0..1
BindingType of specimen container
For example codes, see SpecimenContainer
TypeCodeableConcept
Specimen.container.capacity
Definition

The capacity (volume or other measure) the container may contain.

Control0..1
TypeQuantity(SimpleQuantity)
Specimen.container.specimenQuantity
Definition

The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type.

Control0..1
TypeQuantity(SimpleQuantity)
Specimen.container.additive[x]
Definition

Introduced substance to preserve, maintain or enhance the specimen. examples: Formalin, Citrate, EDTA.

Control0..1
BindingSubstance added to specimen container
For example codes, see v2 Additive/Preservative
TypeChoice of: CodeableConcept, Reference(QICore-Substance)
[x] NoteSee Choice of Data Types for further information about how to use [x]