Breast Radiology Reporting - 1st for comment ballot

This page is part of the Breast Radiology Report (v0.1.0: Comment Draft) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

BreastRadiologyReport

 

The official URL for this profile is: 

http://hl7.org/fhir/us/breast-radiology/StructureDefinition/breastrad-BreastRadiologyReport

Breast Radiology Diagnostic Report. <br>This diagnostic report is the base of the Breast Radiology Report, and contains a summary of the report findings. <br>Detailed information about the reports document is contained in the Breast Radiology Document linked to by the [resultComposition] field.

This profile builds on USCoreDiagnosticReportProfileNoteExchange.

This profile was published on Fri Aug 02 00:00:00 EDT 2019 as a active by Hl7 - Clinical Interoperability Council.

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 4 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category.coding is sliced based on the value of value:code
  • The element DiagnosticReport.code.coding is sliced based on the value of value:code

Mapping Source

This structure represents the following mapping definition:

breastrad.BreastRadiologyReport maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  BasedOn maps to basedOn
  Status maps to status
  Category maps to category
  ObservationSubjectOfRecord maps to subject
  Code maps to code
  CareContext maps to encounter
  RelevantTime maps to effective[x]
  StatementDateTime maps to issued
  DiagnosticReportPerformer maps to performer
  ResultsInterpreter maps to resultsInterpreter
  Specimen maps to specimen
  Observation maps to result (slice on = $this.resolve().code.coding.code; slice strategy = includes)
  MediaIncluded.CommentOrDescription maps to media.comment
  MediaIncluded.Media maps to media.link
  ConclusionText maps to conclusion
  ConclusionCode maps to conclusionCode
  PresentedForm maps to presentedForm
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport breastrad-BreastRadiologyReport
... extension 1..*Slice: Unordered, Open by value:url
... resultcomposition 1..1ResultComposition
... basedOn Reference(ServiceRequest | US Core MedicationRequest Profile)
... category 1..1
.... coding (Slice Definition)Slice: Unordered, Open by value:code
..... Fixed_RAD Σ1..1CodingCode defined by a terminology system
...... system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code Fixed Value: RAD
... code
.... coding (Slice Definition)Slice: Unordered, Open by value:code
..... Fixed_10193-1 Σ1..1CodingCode defined by a terminology system
...... system Fixed Value: http://loinc.org
...... code Fixed Value: 10193-1
... subject The subject of an observation
... issued 1..1
... performer 0..1Reference(US Core Practitioner Profile | US Core Organization Profile)
... resultsInterpreter 0..1Reference(US Core Practitioner Profile | US Core Organization Profile)
... specimen 0..0
... result 0..0
... conclusion 1..1
... conclusionCode 1..1

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*breastrad-BreastRadiologyReport
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 1..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... resultcomposition 1..1ResultComposition
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | US Core MedicationRequest Profile)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..1CodeableConceptService category
Binding: US Core DiagnosticReport Category (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:code
..... Fixed_RAD Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
Fixed Value: RAD
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:code
..... Fixed_10193-1 Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
Fixed Value: 10193-1
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(US Core Patient Profile)The subject of an observation
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1Time of the report or note
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDateTime this version was made
... performer SΣ0..1Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..1Reference(US Core Practitioner Profile | US Core Organization Profile)Primary result interpreter
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 1..1stringClinical conclusion (interpretation) of test results
... conclusionCode 1..1CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Summary

Mandatory: 0 element (10 nested mandatory elements)
Fixed Value: 4 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.category.coding is sliced based on the value of value:code
  • The element DiagnosticReport.code.coding is sliced based on the value of value:code

Mapping Source

This structure represents the following mapping definition:

breastrad.BreastRadiologyReport maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note:
  Language maps to language
  ImplicitRules maps to implicitRules
  Metadata.VersionId maps to meta.versionId
  Metadata.SourceSystem maps to meta.source
  Metadata.Profile maps to meta.profile
  Metadata.LastUpdated maps to meta.lastUpdated
  Metadata.SecurityLabel maps to meta.security
  Metadata.Tag maps to meta.tag
  Narrative maps to text
  Identifier maps to identifier
  BasedOn maps to basedOn
  Status maps to status
  Category maps to category
  ObservationSubjectOfRecord maps to subject
  Code maps to code
  CareContext maps to encounter
  RelevantTime maps to effective[x]
  StatementDateTime maps to issued
  DiagnosticReportPerformer maps to performer
  ResultsInterpreter maps to resultsInterpreter
  Specimen maps to specimen
  Observation maps to result (slice on = $this.resolve().code.coding.code; slice strategy = includes)
  MediaIncluded.CommentOrDescription maps to media.comment
  MediaIncluded.Media maps to media.link
  ConclusionText maps to conclusion
  ConclusionCode maps to conclusionCode
  PresentedForm maps to presentedForm

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport breastrad-BreastRadiologyReport
... extension 1..*Slice: Unordered, Open by value:url
... resultcomposition 1..1ResultComposition
... basedOn Reference(ServiceRequest | US Core MedicationRequest Profile)
... category 1..1
.... coding (Slice Definition)Slice: Unordered, Open by value:code
..... Fixed_RAD Σ1..1CodingCode defined by a terminology system
...... system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code Fixed Value: RAD
... code
.... coding (Slice Definition)Slice: Unordered, Open by value:code
..... Fixed_10193-1 Σ1..1CodingCode defined by a terminology system
...... system Fixed Value: http://loinc.org
...... code Fixed Value: 10193-1
... subject The subject of an observation
... issued 1..1
... performer 0..1Reference(US Core Practitioner Profile | US Core Organization Profile)
... resultsInterpreter 0..1Reference(US Core Practitioner Profile | US Core Organization Profile)
... specimen 0..0
... result 0..0
... conclusion 1..1
... conclusionCode 1..1

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*breastrad-BreastRadiologyReport
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 1..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
... resultcomposition 1..1ResultComposition
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(ServiceRequest | US Core MedicationRequest Profile)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..1CodeableConceptService category
Binding: US Core DiagnosticReport Category (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:code
..... Fixed_RAD Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
Fixed Value: RAD
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ(Slice Definition)Code defined by a terminology system
Slice: Unordered, Open by value:code
..... Fixed_10193-1 Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ0..1codeSymbol in syntax defined by the system
Fixed Value: 10193-1
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject SΣ1..1Reference(US Core Patient Profile)The subject of an observation
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1Time of the report or note
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ1..1instantDateTime this version was made
... performer SΣ0..1Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..1Reference(US Core Practitioner Profile | US Core Organization Profile)Primary result interpreter
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 1..1stringClinical conclusion (interpretation) of test results
... conclusionCode 1..1CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, TTL), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryextensibleUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreDiagnosticreportReportAndNoteCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

 

Constraints

IdPathDetailsRequirements
dom-2DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4DiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-3DiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-6DiagnosticReportA resource should have narrative for robust management
: text.div.exists()
dom-5DiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
ele-1DiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())