This page is part of the FHIR Specification (v1.4.0: STU 3 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
StructureDefinition for Profiles the diagnostic order to ensure that the services ordered can be identified and evaluated for appropraiteness
{ "resourceType": "StructureDefinition", "id": "gao-diagnosticorder", "text": { "status": "generated", "div": "<div>!-- Snipped for Brevity --></div>" }, "url": "http://hl7.org/fhir/StructureDefinition/gao-diagnosticorder", "name": "GAO Diagnostic Order", "status": "draft", "date": "2015-09-22T20:02:49+10:00", "description": "Profiles the diagnostic order to ensure that the services ordered can be identified and evaluated for appropraiteness", "requirements": "The diagnostic order resource is required to identify the diagnostic service or services that were ordered, and to provide additional details that may be necessary to evaluate the order for appropriateness.", "fhirVersion": "1.4.0", "kind": "resource", "abstract": false, "baseType": "DiagnosticOrder", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DiagnosticOrder", "derivation": "constraint", "snapshot": { "element": [ { "path": "DiagnosticOrder", "short": "A request for a diagnostic service", "definition": "A record of a request for a diagnostic investigation service to be performed.", "min": 0, "max": "*", "base": { "path": "DiagnosticOrder", "min": 0, "max": "*" }, "type": [ { "code": "DiagnosticOrder" } ], "mapping": [ { "identity": "rim", "map": "Observation[classCode=OBS, moodCode=RQO, code<\"diagnostic order\"]" }, { "identity": "w5", "map": "clinical.diagnostics" } ] }, { "path": "DiagnosticOrder.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. 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", "base": { "path": "Resource.id", "min": 0, "max": "*" }, "type": [ { "code": "id" } ], "isSummary": true }, { "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", "base": { "path": "Resource.meta", "min": 0, "max": "*" }, "type": [ { "code": "Meta" } ], "isSummary": true }, { "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", "base": { "path": "Resource.implicitRules", "min": 0, "max": "*" }, "type": [ { "code": "uri" } ], "isModifier": true, "isSummary": 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 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).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "*" }, "type": [ { "code": "code" } ], "binding": { "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", "base": { "path": "DomainResource.text", "min": 0, "max": "*" }, "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": "*", "base": { "path": "DomainResource.contained", "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": "*", "base": { "path": "DomainResource.extension", "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": "*", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.identifier", "short": "Identifiers assigned to this order", "definition": "Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller.", "comments": "The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the [notes section](diagnosticorder.html#4.22.4) below.", "min": 0, "max": "*", "base": { "path": "DiagnosticOrder.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".id" }, { "identity": "w5", "map": "id" } ] }, { "path": "DiagnosticOrder.status", "short": "proposed | draft | planned | requested | received | accepted | in-progress | review | completed | cancelled | suspended | rejected | failed | entered-in-error", "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", "base": { "path": "DiagnosticOrder.status", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isModifier": true, "isSummary": true, "binding": { "strength": "required", "description": "The status of a diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode also 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" }, { "identity": "w5", "map": "status" } ] }, { "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, where the clinician indicates the order is urgent, but the subsequent workflow process overrules the priority for some reason. The effective default value is \"normal\".", "min": 0, "max": "1", "base": { "path": "DiagnosticOrder.priority", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "The clinical priority of a diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-order-priority" } }, "mapping": [ { "identity": "rim", "map": ".priorityCode" }, { "identity": "w5", "map": "grade" } ] }, { "path": "DiagnosticOrder.subject", "short": "Who and/or what test is about", "definition": "On whom or what the investigation is to be performed. 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", "base": { "path": "DiagnosticOrder.subject", "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": "w5", "map": "who.focus" } ] }, { "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", "base": { "path": "DiagnosticOrder.encounter", "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]" }, { "identity": "w5", "map": "context" } ] }, { "path": "DiagnosticOrder.orderer", "short": "Who ordered the test", "definition": "The practitioner that holds legal responsibility for ordering the investigation.", "min": 0, "max": "1", "base": { "path": "DiagnosticOrder.orderer", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner" ] } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": ".participation[typeCode=AUT].role" }, { "identity": "w5", "map": "who.actor" } ] }, { "path": "DiagnosticOrder.reason", "short": "Explanation/Justification for test", "definition": "An explanation or justification for why this diagnostic investigation is being requested. This is often for billing purposes. May relate to the resources referred to in supportingInformation.", "comments": "This may be used to decide how the diagnostic investigation will be performed, or even if it will be performed at all. Use CodeableConcept text element if the data is free (uncoded) text as shown in the [CT Scan example](diagnosticorder-example-di.html).", "min": 0, "max": "*", "base": { "path": "DiagnosticOrder.reason", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "binding": { "strength": "example", "description": "Diagnosis or problem codes justifying the reason for requesting the diagnostic investigation.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/condition-code" } }, "mapping": [ { "identity": "rim", "map": ".reasonCode" } ] }, { "path": "DiagnosticOrder.supportingInformation", "short": "Additional clinical information", "definition": "Additional clinical information about the patient or specimen that may influence test interpretations. This includes observations explicitly requested by the producer(filler) to provide context or supporting information needed to complete the order.", "comments": "This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as \"ask at order entry questions (AOEs)\". Examples include reporting the amount of inspired oxygen for blood gasses, the point in the menstrual cycle for cervical pap tests, and other conditions that influence test interpretations.", "requirements": "Supporting information SHALL be provided if known. This field may be required to facilitate evaluation of appropriateness. The supportingInformation field assists with interpretation of the results, and is not intended to provide the reason or indication for the order (see reason[x] above in the Order resource).", "alias": [ "Ask at order entry question", "AOE" ], "min": 0, "max": "*", "base": { "path": "DiagnosticOrder.supportingInformation", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ], "aggregation": [ "contained", "bundled" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ], "aggregation": [ "contained", "bundled" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ], "aggregation": [ "contained", "bundled" ] } ], "mustSupport": true, "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": "*", "base": { "path": "DiagnosticOrder.specimen", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Specimen" ] } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SPC].role" } ] }, { "id": "event", "path": "DiagnosticOrder.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": "*", "base": { "path": "DiagnosticOrder.event", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "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", "base": { "path": "Element.id", "min": 0, "max": "*" }, "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": "*", "base": { "path": "Element.extension", "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": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "isSummary": 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 | entered-in-error", "definition": "The status for the event.", "min": 1, "max": "1", "base": { "path": "DiagnosticOrder.event.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "The status of a diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode also 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", "base": { "path": "DiagnosticOrder.event.description", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "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/ValueSet/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", "base": { "path": "DiagnosticOrder.event.dateTime", "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 responsible for performing or recording the action.", "min": 0, "max": "1", "base": { "path": "DiagnosticOrder.event.actor", "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.", "requirements": "At least one item SHALL be present in the order to describe the service being performed.", "min": 1, "max": "*", "base": { "path": "DiagnosticOrder.item", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "mapping": [ { "identity": "rim", "map": ".outboundRelationship[typeCode=COMP].target[classCode=OBS, moodCode=OBS]" } ] }, { "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", "base": { "path": "Element.id", "min": 0, "max": "*" }, "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": "*", "base": { "path": "Element.extension", "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": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "isModifier": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "DiagnosticOrder.item.code", "short": "Code to indicate the item (test or panel) being ordered", "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", "base": { "path": "DiagnosticOrder.item.code", "min": 1, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "isSummary": true, "binding": { "strength": "preferred", "description": "Codes for tests/services that can be performed by diagnostic services.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-requests" } }, "mapping": [ { "identity": "v2", "map": "OBX-4" }, { "identity": "rim", "map": ".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": "*", "base": { "path": "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", "short": "Location of requested test (if applicable)", "definition": "Anatomical location where the request test should be performed. This is the target site.", "comments": "If the use case requires BodySite to 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](extension-body-site-instance.html).", "requirements": "The body site SHALL be provided when relevant to the order (e.g., MRI of upper joint, where the location is the shoulder or elbow and the laterality is left or right).", "alias": [ "location" ], "min": 0, "max": "1", "base": { "path": "DiagnosticOrder.item.bodySite", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/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 | entered-in-error", "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", "base": { "path": "DiagnosticOrder.item.status", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "isSummary": true, "binding": { "strength": "required", "description": "The status of a diagnostic order.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/diagnostic-order-status" } }, "mapping": [ { "identity": "rim", "map": ".statusCode also 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": "*", "base": { "path": "DiagnosticOrder.item.event", "min": 0, "max": "*" }, "contentReference": "#event", "isSummary": true, "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=FLFS].source" } ] }, { "path": "DiagnosticOrder.note", "short": "Other notes and comments", "definition": "Any other notes associated with this patient, specimen or order (e.g. \"patient hates needles\").", "requirements": "Sometimes a text justification must be provided instead of coded and structured data. This field must be supported and SHALL be provided if known.", "min": 0, "max": "*", "base": { "path": "DiagnosticOrder.note", "min": 0, "max": "*" }, "type": [ { "code": "Annotation" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] } ] }, "differential": { "element": [ { "path": "DiagnosticOrder", "short": "A request for a diagnostic service", "definition": "A record of a request for a diagnostic investigation service to be performed.", "min": 0, "max": "*", "type": [ { "code": "DiagnosticOrder" } ] }, { "path": "DiagnosticOrder.supportingInformation", "short": "Additional clinical information", "definition": "Additional clinical information about the patient or specimen that may influence test interpretations. This includes observations explicitly requested by the producer(filler) to provide context or supporting information needed to complete the order.", "comments": "This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as \"ask at order entry questions (AOEs)\". Examples include reporting the amount of inspired oxygen for blood gasses, the point in the menstrual cycle for cervical pap tests, and other conditions that influence test interpretations.", "requirements": "Supporting information SHALL be provided if known. This field may be required to facilitate evaluation of appropriateness. The supportingInformation field assists with interpretation of the results, and is not intended to provide the reason or indication for the order (see reason[x] above in the Order resource).", "alias": [ "Ask at order entry question", "AOE" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Observation" ], "aggregation": [ "contained", "bundled" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/Condition" ], "aggregation": [ "contained", "bundled" ] }, { "code": "Reference", "profile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ], "aggregation": [ "contained", "bundled" ] } ], "mustSupport": true }, { "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.", "requirements": "At least one item SHALL be present in the order to describe the service being performed.", "min": 1, "max": "*" }, { "path": "DiagnosticOrder.item.code.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labelled as UserSelected = true.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.\n\nThe service being requested SHALL be provided. This is the service to be evaluated against guidelines.", "min": 1, "max": "*", "type": [ { "code": "Coding" } ], "isSummary": true }, { "path": "DiagnosticOrder.item.bodySite", "short": "Location of requested test (if applicable)", "definition": "Anatomical location where the request test should be performed. This is the target site.", "comments": "If the use case requires BodySite to 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](extension-body-site-instance.html).", "requirements": "The body site SHALL be provided when relevant to the order (e.g., MRI of upper joint, where the location is the shoulder or elbow and the laterality is left or right).", "alias": [ "location" ], "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "strength": "example", "description": "Codes describing anatomical locations. May include laterality.", "valueSetReference": { "reference": "http://hl7.org/fhir/ValueSet/body-site" } } }, { "path": "DiagnosticOrder.note", "short": "Other notes and comments", "definition": "Any other notes associated with this patient, specimen or order (e.g. \"patient hates needles\").", "requirements": "Sometimes a text justification must be provided instead of coded and structured data. This field must be supported and SHALL be provided if known.", "min": 0, "max": "*", "type": [ { "code": "Annotation" } ], "mustSupport": true } ] } }