This page is part of the FHIR Specification (v0.0.82: DSTU 1). 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: USLabDR

The official URL for this profile is: 

http://hl7.org/fhir/StructureDefinition/dr-uslab-uslabdr

US Realm Laboratory Report

This profile was published on Wed, Nov 19, 2014 00:00+1100 as a draft by HL7 International - Orders and Observations WG.

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport.

Summary

Terminology Bindings

  • DiagnosticReport.name.coding SHALL come from LOINC codes (Extensible)
  • DiagnosticReport.codedDiagnosis SHALL come from SNOMED CT findings codes provided as adjunct diagnosis to the report (Extensible)

Required/Prohibited Elements

  • The element DiagnosticReport.name is required
  • The element DiagnosticReport.name.coding is required
  • The element DiagnosticReport.name.coding.system is required
  • The element DiagnosticReport.name.coding.code is required
  • The element DiagnosticReport.status is required
  • The element DiagnosticReport.issued is required
  • The element DiagnosticReport.subject is required
  • The element DiagnosticReport.identifier is required
  • The element DiagnosticReport.identifier.use is required
  • The element DiagnosticReport.identifier.system is required
  • The element DiagnosticReport.identifier.value is required
  • The element DiagnosticReport.requestDetail is required
  • The element DiagnosticReport.diagnostic[x] is required
  • The element DiagnosticReport.imagingStudy is prohibited

This structure is derived from DiagnosticReport.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DiagnosticReportUS Realm Laboratory Report
... 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: Language (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
... name S Σ1..1CodeableConceptUS Realm Laboratory Report Order Code
Binding: DiagnosticReportNames (required)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S1..*CodingCode defined by a terminology system
Binding: USLabObservationName (extensible)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeSymbol in syntax defined by the system
..... display S0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
.... text S0..1stringDisplay text
... status ?! SΣ1..1coderegistered | partial | final | corrected | appended | cancelled | entered-in-error
Binding: DiagnosticReportStatus (required)
... issued S ΣI1..1dateTimeDate this version was released
inv-1: Datetime must be at least to second.
... subject S Σ1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientThe subject of the report, usually, but not always, the patient
... performer S Σ0..1pract-uslab-uslabpractResponsible Diagnostic Service
... encounter Σ0..1EncounterHealth care event when test ordered
... identifier S Σ1..*IdentifierId for external references to this report
.... extension 0..*ExtensionAdditional Content defined by implementations
.... use ?! S1..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required)
.... label 0..1stringDescription of identifier
.... system S1..1uriLab URI
Example: http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri
.... value S1..1stringThe value that is unique
Example: 123456
.... period 0..1PeriodTime period when id is/was valid for use
.... assigner 0..1OrganizationOrganization that issued id (may be just text)
... requestDetail S1..*do-uslab-uslabdoWhat was requested
... serviceCategory Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example)
... diagnostic[x] S Σ1..1dateTime, PeriodSpecimen Collection Datetime or Period
... specimen S0..*spec-uslab-uslabspecSpecimens this report is based on
... result S0..*obs-uslab-uslabobscode, obs-uslab-slabobsquantity, obs-uslab-uslabobsother, obs-uslab-uslabobsratio, obs-uslab-uslabobspanel, obs-uslab-uslabobsrangeObservations - simple, or complex nested groups
... image Σ0..*Key images associated with this report
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1MediaReference to the image source
... conclusion S0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: USLabAdjunctDiagnosis (extensible)
... presentedForm S0..*AttachmentEntire Report as issued

todo

This structure is derived from DiagnosticReport.

Summary

Terminology Bindings

  • DiagnosticReport.name.coding SHALL come from LOINC codes (Extensible)
  • DiagnosticReport.codedDiagnosis SHALL come from SNOMED CT findings codes provided as adjunct diagnosis to the report (Extensible)

Required/Prohibited Elements

  • The element DiagnosticReport.name is required
  • The element DiagnosticReport.name.coding is required
  • The element DiagnosticReport.name.coding.system is required
  • The element DiagnosticReport.name.coding.code is required
  • The element DiagnosticReport.status is required
  • The element DiagnosticReport.issued is required
  • The element DiagnosticReport.subject is required
  • The element DiagnosticReport.identifier is required
  • The element DiagnosticReport.identifier.use is required
  • The element DiagnosticReport.identifier.system is required
  • The element DiagnosticReport.identifier.value is required
  • The element DiagnosticReport.requestDetail is required
  • The element DiagnosticReport.diagnostic[x] is required
  • The element DiagnosticReport.imagingStudy is prohibited

Differential View

This structure is derived from DiagnosticReport.

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DiagnosticReportUS Realm Laboratory Report
... 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: Language (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
... name S Σ1..1CodeableConceptUS Realm Laboratory Report Order Code
Binding: DiagnosticReportNames (required)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding S1..*CodingCode defined by a terminology system
Binding: USLabObservationName (extensible)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriIdentity of the terminology system
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeSymbol in syntax defined by the system
..... display S0..1stringRepresentation defined by the system
..... primary 0..1booleanIf this code was chosen directly by the user
.... text S0..1stringDisplay text
... status ?! SΣ1..1coderegistered | partial | final | corrected | appended | cancelled | entered-in-error
Binding: DiagnosticReportStatus (required)
... issued S ΣI1..1dateTimeDate this version was released
inv-1: Datetime must be at least to second.
... subject S Σ1..1patient-uslab-uslabpatient, patient-uslab-uslabphpatientThe subject of the report, usually, but not always, the patient
... performer S Σ0..1pract-uslab-uslabpractResponsible Diagnostic Service
... encounter Σ0..1EncounterHealth care event when test ordered
... identifier S Σ1..*IdentifierId for external references to this report
.... extension 0..*ExtensionAdditional Content defined by implementations
.... use ?! S1..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required)
.... label 0..1stringDescription of identifier
.... system S1..1uriLab URI
Example: http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri
.... value S1..1stringThe value that is unique
Example: 123456
.... period 0..1PeriodTime period when id is/was valid for use
.... assigner 0..1OrganizationOrganization that issued id (may be just text)
... requestDetail S1..*do-uslab-uslabdoWhat was requested
... serviceCategory Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example)
... diagnostic[x] S Σ1..1dateTime, PeriodSpecimen Collection Datetime or Period
... specimen S0..*spec-uslab-uslabspecSpecimens this report is based on
... result S0..*obs-uslab-uslabobscode, obs-uslab-slabobsquantity, obs-uslab-uslabobsother, obs-uslab-uslabobsratio, obs-uslab-uslabobspanel, obs-uslab-uslabobsrangeObservations - simple, or complex nested groups
... image Σ0..*Key images associated with this report
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1MediaReference to the image source
... conclusion S0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: USLabAdjunctDiagnosis (extensible)
... presentedForm S0..*AttachmentEntire Report as issued

XML Template

JSON Template

todo

 

Other representations of profile: (todo)

Terminology Bindings

PathNameConformanceValueSet
DiagnosticReport.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
DiagnosticReport.nameDiagnosticReportNamesrequiredLOINC Diagnostic Report Codes
DiagnosticReport.name.codingUSLabObservationNameextensibleUS Laboratory Observation Profile Observation Name Codes
DiagnosticReport.statusDiagnosticReportStatusrequiredDiagnosticReportStatus
DiagnosticReport.identifier.useIdentifierUserequiredIdentifierUse
DiagnosticReport.serviceCategoryDiagnosticServiceSectionexampleDiagnostic Service Section Codes
DiagnosticReport.codedDiagnosisUSLabAdjunctDiagnosisextensibleSNOMED CT Clinical Findings

Constraints

IdPathNameDetails
inv-1DiagnosticReport.issueddatetime to secondDatetime must be at least to second.
XPath: f:matches(issued,/\d{4}-[01]\d-[0-3]\dT[0-2]\d:[0-5]\d([+-][0-2]\d:[0-5]\d|Z)/)
.