STU 3 Candidate

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

M.?? StructureDefinition: C-CDA on FHIR Diagnostic Imaging

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/ccda-diagnostic-imaging-composition

A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialist’s interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patient’s medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

This profile was published on [no date] with unknown status '" by .

M.??.1 Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

This structure is derived from Composition.

Summary

Mandatory: 5 elements (+4 nested mandatory elements)
Fixed Value: 2 elements

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*DomainResource
... type 1..1CodeableConcepttype
Binding: LOINC Imaging Document Codes (preferred)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementsection
.... title 1..1stringtitle
Fixed Value: Findings
.... code 1..1CodeableConceptcode
.... text 1..1Narrativetext
... section 0..1BackboneElementsection
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Fixed Value: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text 1..1Narrativetext
... section 0..*BackboneElementsection
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: 2467 (preferred)
.... text 0..1Narrativetext

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*DomainResourceA set of resources composed into a single coherent clinical statement with clinical attestation
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑0..1IdentifierLogical identifier of composition (version-independent)
... date ∑1..1dateTimeComposition editing time
... type ∑1..1CodeableConcepttype
Binding: LOINC Imaging Document Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringHuman Readable name/title
... status ?! ∑1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! ∑0..1codeAs defined by affinity domain
Binding: v3 Code System Confidentiality (required)
... subject ∑1..1Reference(Resource)Who and/or what the composition is about
... author ∑1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the composition
... attester ∑0..*BackboneElementAttests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... custodian ∑0..1Reference(Organization)Organization which maintains the composition
... event ∑0..*BackboneElementThe clinical service(s) being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
... section I1..1BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
Fixed Value: Findings
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
.... text I1..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section
... section I0..1BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text I1..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section
... section I0..*BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: 2467 (preferred)
.... text I0..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section

doco Documentation for this format

todo

This structure is derived from Composition.

Summary

Mandatory: 5 elements (+4 nested mandatory elements)
Fixed Value: 2 elements

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

Differential View

This structure is derived from Composition.

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*DomainResource
... type 1..1CodeableConcepttype
Binding: LOINC Imaging Document Codes (preferred)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementsection
.... title 1..1stringtitle
Fixed Value: Findings
.... code 1..1CodeableConceptcode
.... text 1..1Narrativetext
... section 0..1BackboneElementsection
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Fixed Value: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text 1..1Narrativetext
... section 0..*BackboneElementsection
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: 2467 (preferred)
.... text 0..1Narrativetext

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*DomainResourceA set of resources composed into a single coherent clinical statement with clinical attestation
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?! ∑0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: IETF BCP-47 (required)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑0..1IdentifierLogical identifier of composition (version-independent)
... date ∑1..1dateTimeComposition editing time
... type ∑1..1CodeableConcepttype
Binding: LOINC Imaging Document Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringHuman Readable name/title
... status ?! ∑1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... confidentiality ?! ∑0..1codeAs defined by affinity domain
Binding: v3 Code System Confidentiality (required)
... subject ∑1..1Reference(Resource)Who and/or what the composition is about
... author ∑1..*Reference(Practitioner | Device | Patient | RelatedPerson)Who and/or what authored the composition
... attester ∑0..*BackboneElementAttests to accuracy of composition
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(Patient | Practitioner | Organization)Who attested the composition
... custodian ∑0..1Reference(Organization)Organization which maintains the composition
... event ∑0..*BackboneElementThe clinical service(s) being documented
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
... section I1..1BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
Fixed Value: Findings
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
.... text I1..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section
... section I0..1BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
Fixed Value: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text I1..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section
... section I0..*BackboneElementsection
cmp-2: A section can only have an emptyReason if it is empty
cmp-1: A section must at least one of text, entries, or sub-sections
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?! ∑0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: 2467 (preferred)
.... text I0..1Narrativetext
.... mode ?! ∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #section
Nested Section

doco Documentation for this format

XML Template

JSON Template

todo

 

Other representations of profile: Schematron

M.??.2 Terminology Bindings

PathNameConformanceValueSet
Composition.language?extrequiredhttp://tools.ietf.org/html/bcp47
Composition.typeLOINC Imaging Document CodespreferredLOINC Imaging Document Codes
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityv3 Code System Confidentialityrequiredv3 Code System Confidentiality
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.event.codev3 Code System ActCodeexamplev3 Code System ActCode
Composition.section.code?extpreferredValueSet/2467
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.code?extpreferredValueSet/2467
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.code?extpreferredValueSet/2467
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons

M.??.3 Constraints

IdPathDetailsRequirements
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
.