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 for US Realm Laboratory Report
{
"resourceType": "StructureDefinition",
"id": "dr-uslab-uslabdr",
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"url": "http://hl7.org/fhir/StructureDefinition/dr-uslab-uslabdr",
"name": "US Laboratory Diagnostic Report Profile",
"publisher": "HL7 International - Orders and Observations WG",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://hl7.org"
}
]
}
],
"description": "US Realm Laboratory Report",
"status": "draft",
"date": "2014-11-19",
"type": "constraint",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/DiagnosticReport",
"snapshot": {
"element": [
{
"path": "DiagnosticReport",
"name": "USLabDR",
"short": "US Realm Laboratory Report",
"definition": "The scope is the sending of lab results from a laboratory to an ambulatory provider.",
"comments": "This is intended to capture a single report, and is not suitable for use in displaying summary information that covers multiple reports. For example, this resource has not been designed for laboratory cumulative reporting formats nor detailed structured reports for sequencing.",
"requirements": "To support reporting for any diagnostic report into a clinical data repository.",
"alias": [
"Report",
"Test",
"Result",
"Results",
"Labs",
"Laboratory",
"Lab Result",
"Lab Report"
],
"min": 1,
"max": "1",
"type": [
{
"code": "DiagnosticReport"
}
],
"mapping": [
{
"identity": "rim",
"map": "Observation[classCode=OBS, moodCode=EVN]"
}
]
},
{
"path": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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": "DiagnosticReport.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"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DiagnosticReport.name",
"short": "US Realm Laboratory Report Order Code",
"definition": "The laboratory test, panel or battery that was ordered.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"mustSupport": true,
"isSummary": true,
"binding": {
"name": "DiagnosticReportNames",
"strength": "required",
"description": "Codes that describe Diagnostic Reports",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/report-names"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBR-4-Universal Service ID (V2 doesn't provide an easy way to indicate both the ordered test and the performed panel)"
},
{
"identity": "rim",
"map": "code"
}
]
},
{
"path": "DiagnosticReport.name.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": "DiagnosticReport.name.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": "DiagnosticReport.name.coding",
"name": "USLabLOINCCoding",
"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 V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.",
"requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.",
"min": 1,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"mustSupport": true,
"binding": {
"name": "USLabObservationName",
"strength": "extensible",
"description": "LOINC codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/obs-uslab-codes"
}
},
"mapping": [
{
"identity": "v2",
"map": "C*E.1-8, C*E.10-22"
},
{
"identity": "rim",
"map": "union(., ./translation)"
}
]
},
{
"path": "DiagnosticReport.name.coding.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": "DiagnosticReport.name.coding.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": "DiagnosticReport.name.coding.system",
"short": "Identity of the terminology system",
"definition": "The identification of the code system that defines the meaning of the symbol in the code.",
"comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.",
"requirements": "Need to be unambiguous about the source of the definition of the symbol.",
"min": 1,
"max": "1",
"type": [
{
"code": "uri"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "C*E.3"
},
{
"identity": "rim",
"map": "./codeSystem"
}
]
},
{
"path": "DiagnosticReport.name.coding.version",
"short": "Version of the system - if relevant",
"definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.",
"comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "v2",
"map": "C*E.7"
},
{
"identity": "rim",
"map": "./codeSystemVersion"
}
]
},
{
"path": "DiagnosticReport.name.coding.code",
"short": "Symbol in syntax defined by the system",
"definition": "A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).",
"requirements": "Need to refer to a particular code in the system.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "C*E.1"
},
{
"identity": "rim",
"map": "./code"
}
]
},
{
"path": "DiagnosticReport.name.coding.display",
"short": "Representation defined by the system",
"definition": "A representation of the meaning of the code in the system, following the rules of the system.",
"requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "C*E.2 - but note this is not well followed"
},
{
"identity": "rim",
"map": "CV.displayName"
}
]
},
{
"path": "DiagnosticReport.name.coding.primary",
"short": "If this code was chosen directly by the user",
"definition": "Indicates that this code was chosen by a user directly - i.e. off a pick list of available items (codes or displays).",
"comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations.",
"requirements": "This has been identified as a clinical safety criterium - that this exact code was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
"min": 0,
"max": "1",
"type": [
{
"code": "boolean"
}
],
"mapping": [
{
"identity": "v2",
"map": "Sometimes implied by being first"
},
{
"identity": "rim",
"map": "CD.codingRationale"
}
]
},
{
"path": "DiagnosticReport.name.text",
"short": "Display text",
"definition": "This is the laboratory defined display text for the report if different from the code display text(s).",
"comments": "Very often the text is the same as a displayName of one of the codings.",
"requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "C*E.9. But note many systems use C*E.2 for this"
},
{
"identity": "rim",
"map": "./originalText[mediaType/code=\"text/plain\"]/data"
}
]
},
{
"path": "DiagnosticReport.status",
"short": "registered | partial | final | corrected | appended | cancelled | entered-in-error",
"definition": "The status of the diagnostic report as a whole.",
"comments": "This is labeled as \"Is Modifier\" because applications need to take appropriate action if a report is withdrawn.",
"requirements": "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"isModifier": true,
"isSummary": true,
"binding": {
"name": "DiagnosticReportStatus",
"strength": "required",
"description": "The status of the diagnostic report as a whole",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/diagnostic-report-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBR-25-Result Status (not 1:1 mapping)"
},
{
"identity": "rim",
"map": "statusCode\n\nNote: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\""
}
]
},
{
"path": "DiagnosticReport.issued",
"short": "Date this version was released",
"definition": "The date and/or time that this version of the report was released from the source diagnostic service.",
"comments": "May be different from the update time of the resource itself, because that is the status of the record (potentially a secondary copy), not the actual release time of the report .",
"requirements": "Clinicians need to be able to check the date that the report was released.",
"alias": [
"Date Created",
"Date published",
"Date Issued"
],
"min": 1,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"constraint": [
{
"key": "inv-1",
"name": "datetime to second",
"severity": "error",
"human": "Datetime 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)/)"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "OBR-22-Results Rpt/Status Chng - Date/Time"
},
{
"identity": "rim",
"map": "participation[typeCode=VRF or AUT].time"
}
]
},
{
"path": "DiagnosticReport.subject",
"short": "The subject of the report, usually, but not always, the patient",
"definition": "The subject of the report. Usually, but not always, this is a patient. However diagnostic services also perform analyses on specimens collected from a variety of other sources.",
"requirements": "SHALL know the subject context.",
"alias": [
"Patient"
],
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/patient-uslab-uslabpatient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/patient-uslab-uslabphpatient"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PID-3-Patient ID List (no V2 mapping for Group or Device)"
},
{
"identity": "rim",
"map": "participation[typeCode=SBJ]"
}
]
},
{
"path": "DiagnosticReport.performer",
"short": "Responsible Diagnostic Service",
"definition": "The diagnostic service that is responsible for issuing the report.",
"comments": "This is not necessarily the source of the atomic data items - it is the entity that takes responsibility for the clinical report.",
"requirements": "Need to know whom to contact if there are queries about the results. Also may need to track the source of reports for secondary data analysis.",
"alias": [
"Laboratory",
"Service",
"Practitioner",
"Department",
"Company"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/pract-uslab-uslabpract"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PRT-8-Participation Organization (where this PRT-4-Participation = \"PO\")"
},
{
"identity": "rim",
"map": "participation[typeCode=AUT].role[classCode=ASSIGN].scoper"
}
]
},
{
"path": "DiagnosticReport.encounter",
"short": "Health care event when test ordered",
"definition": "The link to the health care event (encounter) when the order was 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": "DiagnosticReport.identifier",
"short": "Id for external references to this report",
"definition": "The local ID assigned to the report by the order filler, usually by the Information System of the diagnostic service provider.",
"requirements": "Need to know what identifier to use when making queries about this report from the source laboratory, and for linking to the report outside FHIR context.",
"alias": [
"ReportID"
],
"min": 1,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "OBR-51-Observation Group ID (todo: check semantic intent of OBR-51 with OOWG)"
},
{
"identity": "rim",
"map": "id"
}
]
},
{
"path": "DiagnosticReport.identifier.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": "DiagnosticReport.identifier.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": "DiagnosticReport.identifier.use",
"short": "usual | official | temp | secondary (If known)",
"definition": "The purpose of this identifier.",
"comments": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.",
"requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"mustSupport": true,
"isModifier": true,
"binding": {
"name": "IdentifierUse",
"strength": "required",
"description": "Identifies the purpose for this identifier, if known",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/identifier-use"
}
},
"mapping": [
{
"identity": "v2",
"map": "N/A"
},
{
"identity": "rim",
"map": "Role.code or implied by context"
}
]
},
{
"path": "DiagnosticReport.identifier.label",
"short": "Description of identifier",
"definition": "A text string for the identifier that can be displayed to a human so they can recognize the identifier.",
"requirements": "Allows humans to make use of identifiers when the identifier system is not known.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "v2",
"map": "CX.5"
},
{
"identity": "rim",
"map": "Role.title or implied by context"
}
]
},
{
"path": "DiagnosticReport.identifier.system",
"short": "Lab URI",
"definition": "The URI for the laboratory Issuing the report. This establishes the namespace in which set of possible id values is unique.",
"requirements": "There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.",
"min": 1,
"max": "1",
"type": [
{
"code": "uri"
}
],
"exampleUri": "http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri",
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "CX.4 / EI-2-4"
},
{
"identity": "rim",
"map": "II.root or Role.id.root"
},
{
"identity": "servd",
"map": "./IdentifierType"
}
]
},
{
"path": "DiagnosticReport.identifier.value",
"short": "The value that is unique",
"definition": "The portion of the identifier typically displayed to the user and which is unique within the context of the system.",
"comments": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.",
"min": 1,
"max": "1",
"type": [
{
"code": "string"
}
],
"exampleString": "123456",
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "CX.1 / EI.1"
},
{
"identity": "rim",
"map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)"
},
{
"identity": "servd",
"map": "./Value"
}
]
},
{
"path": "DiagnosticReport.identifier.period",
"short": "Time period when id is/was valid for use",
"definition": "Time period during which identifier is/was valid for use.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "v2",
"map": "CX.7 + CX.8"
},
{
"identity": "rim",
"map": "Role.effectiveTime or implied by context"
},
{
"identity": "servd",
"map": "./StartDate and ./EndDate"
}
]
},
{
"path": "DiagnosticReport.identifier.assigner",
"short": "Organization that issued id (may be just text)",
"definition": "Organization that issued/manages the identifier.",
"comments": "The reference may be just a text description of the assigner.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"mapping": [
{
"identity": "v2",
"map": "CX.4 / (CX.4,CX.9,CX.10)"
},
{
"identity": "rim",
"map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper"
},
{
"identity": "servd",
"map": "./IdentifierIssuingAuthority"
}
]
},
{
"path": "DiagnosticReport.requestDetail",
"short": "What was requested",
"definition": "Details concerning a test requested.",
"comments": "Note: Usually there is one test request for each result, however in some circumstances multiple test requests may be represented using a single test result resource. Note that there are also cases where one request leads to multiple reports.",
"requirements": "Need to be able to track completion of requests based on reports issued and also to report what diagnostic tests were requested (not always the same as what is delivered).",
"min": 1,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/do-uslab-uslabdo"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=FLFS].target"
}
]
},
{
"path": "DiagnosticReport.serviceCategory",
"short": "Biochemistry, Hematology etc.",
"definition": "The section of the diagnostic service that performs the examination e.g. biochemistry, hematology, MRI.",
"requirements": "Help clinicians filter/find the reports they are looking for.",
"alias": [
"Department",
"Sub-department",
"service",
"discipline"
],
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"name": "DiagnosticServiceSection",
"strength": "example",
"description": "Codes for diagnostic service sections",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/diagnostic-service-sections"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBR-24-Diagnostic Service Section ID"
},
{
"identity": "rim",
"map": "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code"
}
]
},
{
"path": "DiagnosticReport.diagnostic[x]",
"short": "Specimen Collection Datetime or Period",
"definition": "This is the Specimen Collection Datetime or Period which is the physically relevent dateTime for laboratory tests.",
"comments": "If the diagnostic procedure was performed on the patient, this is the time it was performed. If there are specimens, the diagnostically relevant time can be derived from the specimen collection times, but the specimen information is not always available, and the exact relationship between the specimens and the diagnostically relevant time is not always automatic.",
"requirements": "Need to know where in the patient history to file/present this report.",
"alias": [
"Observation time",
"Effective Time"
],
"min": 1,
"max": "1",
"type": [
{
"code": "dateTime"
},
{
"code": "Period"
}
],
"mustSupport": true,
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "OBR-7-Observation Date/Time"
},
{
"identity": "rim",
"map": "effectiveTime"
}
]
},
{
"path": "DiagnosticReport.specimen",
"short": "Specimens this report is based on",
"definition": "Details about the specimens on which this diagnostic report is based.",
"comments": "If the specimen is sufficiently specified with a code in the Test result name, then this additional data may be redundant. If there are multiple specimens, these may be represented per Observation or group.",
"requirements": "Need to be able to report information about the collected specimens on which the report is based.",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/spec-uslab-uslabspec"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "SPM"
},
{
"identity": "rim",
"map": "participation[typeCode=SBJ]"
}
]
},
{
"path": "DiagnosticReport.result",
"short": "Observations - simple, or complex nested groups",
"definition": "Observations that are part of this diagnostic report. Observations can be simple name/value pairs (e.g. \"atomic\" results), or they can be grouping observations that include references to other members of the group (e.g. \"panels\").",
"requirements": "Need to be able to individual results, or report groups of results, where the result grouping is arbitrary, but meaningful. This structure is recursive - observations can contain observations.",
"alias": [
"Data",
"Atomic Value",
"Result",
"Atomic result",
"Data",
"Test",
"Analyte",
"Battery",
"Organiser"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobscode"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-slabobsquantity"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsother"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsratio"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobspanel"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsrange"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=COMP].target"
}
]
},
{
"path": "DiagnosticReport.imagingStudy",
"short": "Reference to full details of imaging associated with the diagnostic report",
"definition": "One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images.",
"comments": "ImagingStudy and image are somewhat overlapping - typically, an image in the image list will also be found in the imaging study resource. However the imaging study and image lists cater to different types of displays for different types of purposes. Neither, either, or both may be provided.",
"min": 0,
"max": "0",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/ImagingStudy"
}
],
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]"
}
]
},
{
"path": "DiagnosticReport.image",
"short": "Key images associated with this report",
"definition": "A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest).",
"requirements": "Many diagnostic services include images in the report as part of their service.",
"alias": [
"DICOM",
"Slides",
"Scans"
],
"min": 0,
"max": "*",
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "OBX?"
},
{
"identity": "rim",
"map": "outboundRelationship[typeCode=COMP].target"
}
]
},
{
"path": "DiagnosticReport.image.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": "DiagnosticReport.image.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": "DiagnosticReport.image.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"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DiagnosticReport.image.comment",
"short": "Comment about the image (e.g. explanation)",
"definition": "A comment about the image. Typically, this is used to provide an explanation for why the image is included, or to draw the viewer's attention to important features.",
"comments": "The comment should be displayed with the image. It would be common for the report to include additional discussion of the image contents in other sections such as the conclusion.",
"requirements": "The provider of the report should make a comment about each image included in the report.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value"
}
]
},
{
"path": "DiagnosticReport.image.link",
"short": "Reference to the image source",
"definition": "Reference to the image source.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Media"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".value.reference"
}
]
},
{
"path": "DiagnosticReport.conclusion",
"short": "Clinical Interpretation of test results",
"definition": "Concise and clinically contextualized narrative interpretation of the diagnostic report.",
"comments": "Typically, a report is either [all data, no narrative (e.g. Core lab)] or [a mix of data with some concluding narrative (e.g. Structured Pathology Report, Bone Density)], or [all narrative (e.g. typical imaging report, histopathology)]. In all of these cases, the narrative goes in \"text\".",
"requirements": "Need to be able to provide a conclusion that is not lost amongst the basic result data.",
"alias": [
"Report"
],
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "OBX"
},
{
"identity": "rim",
"map": "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)"
}
]
},
{
"path": "DiagnosticReport.codedDiagnosis",
"short": "Codes for the conclusion",
"definition": "Codes for the conclusion.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"mustSupport": true,
"binding": {
"name": "USLabAdjunctDiagnosis",
"strength": "extensible",
"description": "SNOMED CT findings codes provided as adjunct diagnosis to the report",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/uslab-clinical-findings"
}
},
"mapping": [
{
"identity": "v2",
"map": "OBX"
},
{
"identity": "rim",
"map": "inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD)"
}
]
},
{
"path": "DiagnosticReport.presentedForm",
"short": "Entire Report as issued",
"definition": "Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent.",
"comments": "Application/pdf is recommended as the most reliable and interoperable in this context.",
"requirements": "Gives Laboratory the ability to provide its own fully formatted report for clinical fidelity.",
"min": 0,
"max": "*",
"type": [
{
"code": "Attachment"
}
],
"mustSupport": true,
"mapping": [
{
"identity": "v2",
"map": "OBX"
},
{
"identity": "rim",
"map": "text (type=ED)"
}
]
}
]
},
"differential": {
"element": [
{
"path": "DiagnosticReport",
"name": "USLabDR",
"short": "US Realm Laboratory Report",
"definition": "The scope is the sending of lab results from a laboratory to an ambulatory provider.",
"alias": [
"Lab Result",
"Lab Report"
],
"min": 1,
"max": "1",
"type": [
{
"code": "DiagnosticReport"
}
]
},
{
"path": "DiagnosticReport.name",
"short": "US Realm Laboratory Report Order Code",
"definition": "The laboratory test, panel or battery that was ordered.",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.name.coding",
"name": "USLabLOINCCoding",
"min": 1,
"max": "*",
"mustSupport": true,
"binding": {
"name": "USLabObservationName",
"strength": "extensible",
"description": "LOINC codes",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/obs-uslab-codes"
}
}
},
{
"path": "DiagnosticReport.name.coding.system",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.name.coding.code",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.name.coding.display",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.name.text",
"short": "Display text",
"definition": "This is the laboratory defined display text for the report if different from the code display text(s).",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.status",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.issued",
"min": 1,
"max": "1",
"condition": [
"inv-1"
],
"constraint": [
{
"key": "inv-1",
"name": "datetime to second",
"severity": "error",
"human": "Datetime 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)/)"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.subject",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/patient-uslab-uslabpatient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/patient-uslab-uslabphpatient"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.performer",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/pract-uslab-uslabpract"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.identifier",
"min": 1,
"max": "*",
"mustSupport": true
},
{
"path": "DiagnosticReport.identifier.use",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.identifier.system",
"short": "Lab URI",
"definition": "The URI for the laboratory Issuing the report. This establishes the namespace in which set of possible id values is unique.",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.identifier.value",
"min": 1,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.requestDetail",
"min": 1,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/do-uslab-uslabdo"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.diagnostic[x]",
"short": "Specimen Collection Datetime or Period",
"definition": "This is the Specimen Collection Datetime or Period which is the physically relevent dateTime for laboratory tests.",
"min": 1,
"max": "1",
"type": [
{
"code": "dateTime"
},
{
"code": "Period"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.specimen",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/spec-uslab-uslabspec"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.result",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobscode"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-slabobsquantity"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsother"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsratio"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobspanel"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/obs-uslab-uslabobsrange"
}
],
"mustSupport": true
},
{
"path": "DiagnosticReport.imagingStudy",
"min": 0,
"max": "0"
},
{
"path": "DiagnosticReport.conclusion",
"min": 0,
"max": "1",
"mustSupport": true
},
{
"path": "DiagnosticReport.codedDiagnosis",
"min": 0,
"max": "*",
"mustSupport": true,
"binding": {
"name": "USLabAdjunctDiagnosis",
"strength": "extensible",
"description": "SNOMED CT findings codes provided as adjunct diagnosis to the report",
"valueSetReference": {
"reference": "http://hl7.org/fhir/vs/uslab-clinical-findings"
}
}
},
{
"path": "DiagnosticReport.presentedForm",
"min": 0,
"max": "*",
"mustSupport": true
}
]
}
}
© HL7.org 2011+. FHIR DSTU (v0.4.0-4902) generated on Fri, Mar 27, 2015 00:19+1100.
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