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 
{
"resourceType" : "StructureDefinition",
"id" : "breastrad-BreastRadiologyReport",
"text" : {
"status" : "generated",
"div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n <p><b>BreastRadiologyReport Profile</b></p>\n <p>Breast Radiology Diagnostic Report.\n<br>This diagnostic report is the base of the Breast Radiology Report, and contains a summary of the report findings.\n<br>Detailed information about the reports document is contained in the Breast Radiology Document linked to by the [resultComposition] field.</p>\n <p><b>Mapping Summary</b></p>\n <p><pre>breastrad.BreastRadiologyReport maps to http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note:\n Language maps to language\n ImplicitRules maps to implicitRules\n Metadata.VersionId maps to meta.versionId\n Metadata.SourceSystem maps to meta.source\n Metadata.Profile maps to meta.profile\n Metadata.LastUpdated maps to meta.lastUpdated\n Metadata.SecurityLabel maps to meta.security\n Metadata.Tag maps to meta.tag\n Narrative maps to text\n Identifier maps to identifier\n BasedOn maps to basedOn\n Status maps to status\n Category maps to category\n ObservationSubjectOfRecord maps to subject\n Code maps to code\n CareContext maps to encounter\n RelevantTime maps to effective[x]\n StatementDateTime maps to issued\n DiagnosticReportPerformer maps to performer\n ResultsInterpreter maps to resultsInterpreter\n Specimen maps to specimen\n Observation maps to result (slice on = $this.resolve().code.coding.code; slice strategy = includes)\n MediaIncluded.CommentOrDescription maps to media.comment\n MediaIncluded.Media maps to media.link\n ConclusionText maps to conclusion\n ConclusionCode maps to conclusionCode\n PresentedForm maps to presentedForm\n</pre></p>\n</div>"
},
"url" : "http://hl7.org/fhir/us/breast-radiology/StructureDefinition/breastrad-BreastRadiologyReport",
"version" : "0.1.0",
"name" : "BreastRadiologyReport",
"title" : "breastrad-BreastRadiologyReport",
"status" : "active",
"date" : "2019-08-02T00:00:00-04:00",
"publisher" : "Hl7 - Clinical Interoperability Council",
"contact" : [
{
"telecom" : [
{
"system" : "url",
"value" : "http://www.hl7.org/Special/committees/cic"
}
]
}
],
"description" : "Breast Radiology Diagnostic Report.\n<br>This diagnostic report is the base of the Breast Radiology Report, and contains a summary of the report findings.\n<br>Detailed information about the reports document is contained in the Breast Radiology Document linked to by the [resultComposition] field.",
"jurisdiction" : [
{
"coding" : [
{
"system" : "urn:iso:std:iso:3166",
"code" : "US",
"display" : "United States of America"
}
]
}
],
"fhirVersion" : "4.0.0",
"mapping" : [
{
"identity" : "workflow",
"uri" : "http://hl7.org/fhir/workflow",
"name" : "Workflow Pattern"
},
{
"identity" : "v2",
"uri" : "http://hl7.org/v2",
"name" : "HL7 v2 Mapping"
},
{
"identity" : "rim",
"uri" : "http://hl7.org/v3",
"name" : "RIM Mapping"
},
{
"identity" : "w5",
"uri" : "http://hl7.org/fhir/fivews",
"name" : "FiveWs Pattern Mapping"
}
],
"kind" : "resource",
"abstract" : false,
"type" : "DiagnosticReport",
"baseDefinition" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note",
"derivation" : "constraint",
"snapshot" : {
"element" : [
{
"id" : "DiagnosticReport",
"path" : "DiagnosticReport",
"short" : "breastrad-BreastRadiologyReport",
"definition" : "Breast Radiology Diagnostic Report.\n<br>This diagnostic report is the base of the Breast Radiology Report, and contains a summary of the report findings.\n<br>Detailed information about the reports document is contained in the Breast Radiology Document linked to by the [resultComposition] field.",
"comment" : "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.",
"alias" : [
"Report",
"Test",
"Result",
"Results",
"Labs",
"Laboratory",
"Imaging Report",
"Radiology Report"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DiagnosticReport",
"min" : 0,
"max" : "*"
},
"constraint" : [
{
"key" : "dom-2",
"severity" : "error",
"human" : "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression" : "contained.contained.empty()",
"xpath" : "not(parent::f:contained and f:contained)",
"source" : "DomainResource"
},
{
"key" : "dom-4",
"severity" : "error",
"human" : "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression" : "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath" : "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))",
"source" : "DomainResource"
},
{
"key" : "dom-3",
"severity" : "error",
"human" : "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource",
"expression" : "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()",
"xpath" : "not(exists(for $contained in f:contained return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))",
"source" : "DomainResource"
},
{
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice",
"valueBoolean" : true
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation",
"valueMarkdown" : "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time."
}
],
"key" : "dom-6",
"severity" : "warning",
"human" : "A resource should have narrative for robust management",
"expression" : "text.div.exists()",
"xpath" : "exists(f:text/h:div)",
"source" : "DomainResource"
},
{
"key" : "dom-5",
"severity" : "error",
"human" : "If a resource is contained in another resource, it SHALL NOT have a security label",
"expression" : "contained.meta.security.empty()",
"xpath" : "not(exists(f:contained/*/f:meta/f:security))",
"source" : "DomainResource"
}
],
"mustSupport" : false,
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "Entity. Role, or Act"
},
{
"identity" : "workflow",
"map" : "Event"
},
{
"identity" : "v2",
"map" : "ORU -> OBR"
},
{
"identity" : "rim",
"map" : "Observation[classCode=OBS, moodCode=EVN]"
}
]
},
{
"id" : "DiagnosticReport.id",
"path" : "DiagnosticReport.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.",
"comment" : "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "id"
}
],
"isModifier" : false,
"isSummary" : true
},
{
"id" : "DiagnosticReport.meta",
"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 might not always be associated with version changes to the resource.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.meta",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "Meta"
}
],
"isModifier" : false,
"isSummary" : true
},
{
"id" : "DiagnosticReport.implicitRules",
"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. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.",
"comment" : "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. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Resource.implicitRules",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "uri"
}
],
"isModifier" : true,
"isModifierReason" : "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation",
"isSummary" : true
},
{
"id" : "DiagnosticReport.language",
"path" : "DiagnosticReport.language",
"short" : "Language of the resource content",
"definition" : "The base language in which the resource is written.",
"comment" : "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" : "1"
},
"type" : [
{
"code" : "code"
}
],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueCanonical" : "http://hl7.org/fhir/ValueSet/all-languages"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "Language"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean" : true
}
],
"strength" : "preferred",
"description" : "A human language.",
"valueSet" : "http://hl7.org/fhir/ValueSet/languages"
}
},
{
"id" : "DiagnosticReport.text",
"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 can 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.",
"comment" : "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.",
"alias" : [
"narrative",
"html",
"xhtml",
"display"
],
"min" : 0,
"max" : "1",
"base" : {
"path" : "DomainResource.text",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "Narrative"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "Act.text?"
}
]
},
{
"id" : "DiagnosticReport.contained",
"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.",
"comment" : "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. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.",
"alias" : [
"inline resources",
"anonymous resources",
"contained resources"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.contained",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Resource"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "N/A"
}
]
},
{
"id" : "DiagnosticReport.extension",
"path" : "DiagnosticReport.extension",
"slicing" : {
"id" : "3",
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"ordered" : false,
"rules" : "open"
},
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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" : 1,
"max" : "*",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "N/A"
}
]
},
{
"id" : "DiagnosticReport.extension:resultcomposition",
"path" : "DiagnosticReport.extension",
"sliceName" : "resultcomposition",
"definition" : "Reference to the document containing detailed information about the breast radiology report, including assocated sections",
"min" : 1,
"max" : "1",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : [
"http://hl7.org/fhir/us/breast-radiology/StructureDefinition/breastrad-ResultComposition-extension"
]
}
],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "DiagnosticReport.modifierExtension",
"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 and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "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.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"alias" : [
"extensions",
"user content"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DomainResource.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension"
}
],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them",
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "N/A"
}
]
},
{
"id" : "DiagnosticReport.identifier",
"path" : "DiagnosticReport.identifier",
"short" : "Business identifier for report",
"definition" : "Identifiers assigned to this report by the performer or other systems.",
"comment" : "Usually assigned by the Information System of the diagnostic service provider (filler id).",
"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",
"Filler ID",
"Placer ID"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DiagnosticReport.identifier",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Identifier"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.identifier"
},
{
"identity" : "w5",
"map" : "FiveWs.identifier"
},
{
"identity" : "v2",
"map" : "OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4"
},
{
"identity" : "rim",
"map" : "id"
}
]
},
{
"id" : "DiagnosticReport.basedOn",
"path" : "DiagnosticReport.basedOn",
"short" : "What was requested",
"definition" : "Details concerning a service requested.",
"comment" : "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" : "This allows tracing of authorization for the report and tracking whether proposals/recommendations were acted upon.",
"alias" : [
"Request"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "DiagnosticReport.basedOn",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/ServiceRequest",
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"
]
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.basedOn"
},
{
"identity" : "v2",
"map" : "ORC? OBR-2/3?"
},
{
"identity" : "rim",
"map" : "outboundRelationship[typeCode=FLFS].target"
}
]
},
{
"id" : "DiagnosticReport.status",
"path" : "DiagnosticReport.status",
"short" : "registered | partial | preliminary | final +",
"definition" : "The status of the diagnostic report.",
"requirements" : "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.status",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "code"
}
],
"mustSupport" : true,
"isModifier" : true,
"isModifierReason" : "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary" : true,
"binding" : {
"strength" : "required",
"valueSet" : "http://hl7.org/fhir/ValueSet/diagnostic-report-status"
},
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.status"
},
{
"identity" : "w5",
"map" : "FiveWs.status"
},
{
"identity" : "v2",
"map" : "OBR-25 (not 1:1 mapping)"
},
{
"identity" : "rim",
"map" : "statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\""
}
]
},
{
"id" : "DiagnosticReport.category",
"path" : "DiagnosticReport.category",
"short" : "Service category",
"definition" : "A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes.",
"comment" : "Multiple categories are allowed using various categorization schemes. The level of granularity is defined by the category concepts in the value set. More fine-grained filtering can be performed using the metadata and/or terminology hierarchy in DiagnosticReport.code.",
"alias" : [
"Department",
"Sub-department",
"Service",
"Discipline",
"service",
"discipline"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.category",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"binding" : {
"strength" : "extensible",
"valueSet" : "http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category"
},
"mapping" : [
{
"identity" : "w5",
"map" : "FiveWs.class"
},
{
"identity" : "v2",
"map" : "OBR-24"
},
{
"identity" : "rim",
"map" : "inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code"
}
]
},
{
"id" : "DiagnosticReport.category.id",
"path" : "DiagnosticReport.category.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.category.extension",
"path" : "DiagnosticReport.category.extension",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"description" : "Extensions are always sliced by (at least) url",
"rules" : "open"
},
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.category.coding",
"path" : "DiagnosticReport.category.coding",
"slicing" : {
"id" : "1",
"discriminator" : [
{
"type" : "value",
"path" : "code"
}
],
"ordered" : false,
"rules" : "open"
},
"short" : "Code defined by a terminology system",
"definition" : "A reference to a code defined by a terminology system.",
"comment" : "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 labeled as UserSelected = true.",
"requirements" : "Allows for alternative encodings within a code system, and translations to other code systems.",
"min" : 1,
"max" : "*",
"base" : {
"path" : "CodeableConcept.coding",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Coding"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.1-8, C*E.10-22"
},
{
"identity" : "rim",
"map" : "union(., ./translation)"
},
{
"identity" : "orim",
"map" : "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD",
"path" : "DiagnosticReport.category.coding",
"sliceName" : "Fixed_RAD",
"short" : "Code defined by a terminology system",
"definition" : "A reference to a code defined by a terminology system.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CodeableConcept.coding",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Coding"
}
],
"isSummary" : true
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.id",
"path" : "DiagnosticReport.category.coding.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.extension",
"path" : "DiagnosticReport.category.coding.extension",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"description" : "Extensions are always sliced by (at least) url",
"rules" : "open"
},
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.system",
"path" : "DiagnosticReport.category.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.",
"comment" : "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 reference to some definition that establishes the system clearly and unambiguously.",
"requirements" : "Need to be unambiguous about the source of the definition of the symbol.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Coding.system",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "uri"
}
],
"fixedUri" : "http://terminology.hl7.org/CodeSystem/v2-0074",
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.3"
},
{
"identity" : "rim",
"map" : "./codeSystem"
},
{
"identity" : "orim",
"map" : "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.version",
"path" : "DiagnosticReport.category.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.",
"comment" : "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",
"base" : {
"path" : "Coding.version",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.7"
},
{
"identity" : "rim",
"map" : "./codeSystemVersion"
},
{
"identity" : "orim",
"map" : "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.code",
"path" : "DiagnosticReport.category.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" : 0,
"max" : "1",
"base" : {
"path" : "Coding.code",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "code"
}
],
"fixedCode" : "RAD",
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.1"
},
{
"identity" : "rim",
"map" : "./code"
},
{
"identity" : "orim",
"map" : "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.display",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable",
"valueBoolean" : true
}
],
"path" : "DiagnosticReport.category.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",
"base" : {
"path" : "Coding.display",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.2 - but note this is not well followed"
},
{
"identity" : "rim",
"map" : "CV.displayName"
},
{
"identity" : "orim",
"map" : "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName"
}
]
},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.userSelected",
"path" : "DiagnosticReport.category.coding.userSelected",
"short" : "If this coding was chosen directly by the user",
"definition" : "Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).",
"comment" : "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.",
"requirements" : "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Coding.userSelected",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "boolean"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "Sometimes implied by being first"
},
{
"identity" : "rim",
"map" : "CD.codingRationale"
},
{
"identity" : "orim",
"map" : "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]"
}
]
},
{
"id" : "DiagnosticReport.category.text",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable",
"valueBoolean" : true
}
],
"path" : "DiagnosticReport.category.text",
"short" : "Plain text representation of the concept",
"definition" : "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"comment" : "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",
"base" : {
"path" : "CodeableConcept.text",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : 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"
},
{
"identity" : "orim",
"map" : "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText"
}
]
},
{
"id" : "DiagnosticReport.code",
"path" : "DiagnosticReport.code",
"short" : "US Core Report Code",
"definition" : "The test, panel, report, or note that was ordered.",
"comment" : "UsageNote= The typical patterns for codes are: 1) a LOINC code either as a translation from a \"local\" code or as a primary code, or 2) a local code only if no suitable LOINC exists, or 3) both the local and the LOINC translation. Systems SHALL be capable of sending the local code if one exists.",
"alias" : [
"Type"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.code",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"binding" : {
"strength" : "extensible",
"description" : "LOINC codes",
"valueSet" : "http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes"
},
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.code"
},
{
"identity" : "w5",
"map" : "FiveWs.what[x]"
},
{
"identity" : "v2",
"map" : "OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel)"
},
{
"identity" : "rim",
"map" : "code"
}
]
},
{
"id" : "DiagnosticReport.code.id",
"path" : "DiagnosticReport.code.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.code.extension",
"path" : "DiagnosticReport.code.extension",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"description" : "Extensions are always sliced by (at least) url",
"rules" : "open"
},
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.code.coding",
"path" : "DiagnosticReport.code.coding",
"slicing" : {
"id" : "2",
"discriminator" : [
{
"type" : "value",
"path" : "code"
}
],
"ordered" : false,
"rules" : "open"
},
"short" : "Code defined by a terminology system",
"definition" : "A reference to a code defined by a terminology system.",
"comment" : "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 labeled as UserSelected = true.",
"requirements" : "Allows for alternative encodings within a code system, and translations to other code systems.",
"min" : 1,
"max" : "*",
"base" : {
"path" : "CodeableConcept.coding",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Coding"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.1-8, C*E.10-22"
},
{
"identity" : "rim",
"map" : "union(., ./translation)"
},
{
"identity" : "orim",
"map" : "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1",
"path" : "DiagnosticReport.code.coding",
"sliceName" : "Fixed_10193-1",
"short" : "Code defined by a terminology system",
"definition" : "A reference to a code defined by a terminology system.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "CodeableConcept.coding",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Coding"
}
],
"isSummary" : true
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.id",
"path" : "DiagnosticReport.code.coding.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.extension",
"path" : "DiagnosticReport.code.coding.extension",
"slicing" : {
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"description" : "Extensions are always sliced by (at least) url",
"rules" : "open"
},
"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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.system",
"path" : "DiagnosticReport.code.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.",
"comment" : "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 reference to some definition that establishes the system clearly and unambiguously.",
"requirements" : "Need to be unambiguous about the source of the definition of the symbol.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Coding.system",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "uri"
}
],
"fixedUri" : "http://loinc.org",
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.3"
},
{
"identity" : "rim",
"map" : "./codeSystem"
},
{
"identity" : "orim",
"map" : "fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.version",
"path" : "DiagnosticReport.code.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.",
"comment" : "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",
"base" : {
"path" : "Coding.version",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.7"
},
{
"identity" : "rim",
"map" : "./codeSystemVersion"
},
{
"identity" : "orim",
"map" : "fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.code",
"path" : "DiagnosticReport.code.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" : 0,
"max" : "1",
"base" : {
"path" : "Coding.code",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "code"
}
],
"fixedCode" : "10193-1",
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.1"
},
{
"identity" : "rim",
"map" : "./code"
},
{
"identity" : "orim",
"map" : "fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.display",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable",
"valueBoolean" : true
}
],
"path" : "DiagnosticReport.code.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",
"base" : {
"path" : "Coding.display",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "C*E.2 - but note this is not well followed"
},
{
"identity" : "rim",
"map" : "CV.displayName"
},
{
"identity" : "orim",
"map" : "fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName"
}
]
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.userSelected",
"path" : "DiagnosticReport.code.coding.userSelected",
"short" : "If this coding was chosen directly by the user",
"definition" : "Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).",
"comment" : "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.",
"requirements" : "This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Coding.userSelected",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "boolean"
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "Sometimes implied by being first"
},
{
"identity" : "rim",
"map" : "CD.codingRationale"
},
{
"identity" : "orim",
"map" : "fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\\#true a [ fhir:source \"true\"; fhir:target dt:CDCoding.codingRationale\\#O ]"
}
]
},
{
"id" : "DiagnosticReport.code.text",
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable",
"valueBoolean" : true
}
],
"path" : "DiagnosticReport.code.text",
"short" : "Plain text representation of the concept",
"definition" : "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.",
"comment" : "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",
"base" : {
"path" : "CodeableConcept.text",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : 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"
},
{
"identity" : "orim",
"map" : "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText"
}
]
},
{
"id" : "DiagnosticReport.subject",
"path" : "DiagnosticReport.subject",
"short" : "The subject of an observation",
"definition" : "The subject of an observation.",
"requirements" : "SHALL know the subject context.",
"alias" : [
"Patient"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.subject",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient"
]
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.subject"
},
{
"identity" : "w5",
"map" : "FiveWs.subject[x]"
},
{
"identity" : "v2",
"map" : "PID-3 (no HL7 v2 mapping for Group or Device)"
},
{
"identity" : "rim",
"map" : "participation[typeCode=SBJ]"
},
{
"identity" : "w5",
"map" : "FiveWs.subject"
}
]
},
{
"id" : "DiagnosticReport.encounter",
"path" : "DiagnosticReport.encounter",
"short" : "Health care event when test ordered",
"definition" : "The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.",
"comment" : "This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).",
"requirements" : "Links the request to the Encounter context.",
"alias" : [
"Context"
],
"min" : 0,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.encounter",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter"
]
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.encounter"
},
{
"identity" : "w5",
"map" : "FiveWs.context"
},
{
"identity" : "v2",
"map" : "PV1-19"
},
{
"identity" : "rim",
"map" : "inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN]"
}
]
},
{
"id" : "DiagnosticReport.effective[x]",
"path" : "DiagnosticReport.effective[x]",
"short" : "Time of the report or note",
"definition" : "This is the Datetime or Period when the report or note was written.",
"comment" : "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",
"Occurrence"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.effective[x]",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "dateTime"
},
{
"code" : "Period"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.occurrence[x]"
},
{
"identity" : "w5",
"map" : "FiveWs.done[x]"
},
{
"identity" : "v2",
"map" : "OBR-7"
},
{
"identity" : "rim",
"map" : "effectiveTime"
}
]
},
{
"id" : "DiagnosticReport.issued",
"path" : "DiagnosticReport.issued",
"short" : "DateTime this version was made",
"definition" : "The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified.",
"comment" : "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 published",
"Date Issued",
"Date Verified"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.issued",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "instant"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "w5",
"map" : "FiveWs.recorded"
},
{
"identity" : "v2",
"map" : "OBR-22"
},
{
"identity" : "rim",
"map" : "participation[typeCode=VRF or AUT].time"
}
]
},
{
"id" : "DiagnosticReport.performer",
"path" : "DiagnosticReport.performer",
"short" : "Responsible Diagnostic Service",
"definition" : "The diagnostic service that is responsible for issuing the report.",
"comment" : "This is not necessarily the source of the atomic data items or the entity that interpreted the results. 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",
"Authorized by",
"Director"
],
"min" : 0,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.performer",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner",
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"
]
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.performer.actor"
},
{
"identity" : "w5",
"map" : "FiveWs.actor"
},
{
"identity" : "v2",
"map" : "PRT-8 (where this PRT-4-Participation = \"PO\")"
},
{
"identity" : "rim",
"map" : ".participation[typeCode=PRF]"
}
]
},
{
"id" : "DiagnosticReport.resultsInterpreter",
"path" : "DiagnosticReport.resultsInterpreter",
"short" : "Primary result interpreter",
"definition" : "The practitioner or organization that is responsible for the report's conclusions and interpretations.",
"comment" : "Might not be the same 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" : [
"Analyzed by",
"Reported by"
],
"min" : 0,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.resultsInterpreter",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner",
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"
]
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "workflow",
"map" : "Event.performer.actor"
},
{
"identity" : "w5",
"map" : "FiveWs.actor"
},
{
"identity" : "v2",
"map" : "OBR-32, PRT-8 (where this PRT-4-Participation = \"PI\")"
},
{
"identity" : "rim",
"map" : ".participation[typeCode=PRF]"
}
]
},
{
"id" : "DiagnosticReport.specimen",
"path" : "DiagnosticReport.specimen",
"short" : "Specimens this report is based on",
"definition" : "Details about the specimens on which this diagnostic report is based.",
"comment" : "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" : "0",
"base" : {
"path" : "DiagnosticReport.specimen",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/Specimen"
]
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "v2",
"map" : "SPM"
},
{
"identity" : "rim",
"map" : "participation[typeCode=SBJ]"
}
]
},
{
"id" : "DiagnosticReport.result",
"path" : "DiagnosticReport.result",
"short" : "Observations",
"definition" : "[Observations](http://hl7.org/fhir/R4/observation.html) that are part of this diagnostic report.",
"comment" : "Observations can contain observations.",
"requirements" : "Need to support individual results, or groups of results, where the result grouping is arbitrary, but meaningful.",
"alias" : [
"Data",
"Atomic Value",
"Result",
"Atomic result",
"Data",
"Test",
"Analyte",
"Battery",
"Organizer"
],
"min" : 0,
"max" : "0",
"base" : {
"path" : "DiagnosticReport.result",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/us/breast-radiology/StructureDefinition/obf-Observation"
]
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "v2",
"map" : "OBXs"
},
{
"identity" : "rim",
"map" : "outboundRelationship[typeCode=COMP].target"
}
]
},
{
"id" : "DiagnosticReport.imagingStudy",
"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.",
"comment" : "ImagingStudy and the image element are somewhat overlapping - typically, the list of image references in the image element will also be found in one of the imaging study resources. However, each caters to different types of displays for different types of purposes. Neither, either, or both may be provided.",
"min" : 0,
"max" : "*",
"base" : {
"path" : "DiagnosticReport.imagingStudy",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/ImagingStudy"
]
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN]"
}
]
},
{
"id" : "DiagnosticReport.media",
"path" : "DiagnosticReport.media",
"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" : "*",
"base" : {
"path" : "DiagnosticReport.media",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "BackboneElement"
}
],
"constraint" : [
{
"key" : "ele-1",
"severity" : "error",
"human" : "All FHIR elements must have a @value or children",
"expression" : "hasValue() or (children().count() > id.count())",
"xpath" : "@value|f:*|h:div",
"source" : "Element"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "v2",
"map" : "OBX?"
},
{
"identity" : "rim",
"map" : "outboundRelationship[typeCode=COMP].target"
}
]
},
{
"id" : "DiagnosticReport.media.id",
"path" : "DiagnosticReport.media.id",
"representation" : [
"xmlAttr"
],
"short" : "Unique id for inter-element referencing",
"definition" : "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min" : 0,
"max" : "1",
"base" : {
"path" : "Element.id",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.media.extension",
"path" : "DiagnosticReport.media.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. 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 can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comment" : "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"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : "n/a"
}
]
},
{
"id" : "DiagnosticReport.media.modifierExtension",
"path" : "DiagnosticReport.media.modifierExtension",
"short" : "Extensions that cannot be ignored even if unrecognized",
"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 in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. 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 can 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.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).",
"comment" : "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.",
"requirements" : "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).",
"alias" : [
"extensions",
"user content",
"modifiers"
],
"min" : 0,
"max" : "*",
"base" : {
"path" : "BackboneElement.modifierExtension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension"
}
],
"isModifier" : true,
"isModifierReason" : "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them",
"isSummary" : true,
"mapping" : [
{
"identity" : "rim",
"map" : "N/A"
}
]
},
{
"id" : "DiagnosticReport.media.comment",
"path" : "DiagnosticReport.media.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.",
"comment" : "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",
"base" : {
"path" : "DiagnosticReport.media.comment",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "rim",
"map" : ".inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value"
}
]
},
{
"id" : "DiagnosticReport.media.link",
"path" : "DiagnosticReport.media.link",
"short" : "Reference to the image source",
"definition" : "Reference to the image source.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.media.link",
"min" : 1,
"max" : "1"
},
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/Media"
]
}
],
"isModifier" : false,
"isSummary" : true,
"mapping" : [
{
"identity" : "rim",
"map" : ".value.reference"
}
]
},
{
"id" : "DiagnosticReport.conclusion",
"path" : "DiagnosticReport.conclusion",
"short" : "Clinical conclusion (interpretation) of test results",
"definition" : "Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report.",
"requirements" : "Need to be able to provide a conclusion that is not lost among the basic result data.",
"alias" : [
"Report"
],
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.conclusion",
"min" : 0,
"max" : "1"
},
"type" : [
{
"code" : "string"
}
],
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "v2",
"map" : "OBX"
},
{
"identity" : "rim",
"map" : "inboundRelationship[typeCode=\"SPRT\"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST)"
}
]
},
{
"id" : "DiagnosticReport.conclusionCode",
"path" : "DiagnosticReport.conclusionCode",
"short" : "Codes for the clinical conclusion of test results",
"definition" : "One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report.",
"min" : 1,
"max" : "1",
"base" : {
"path" : "DiagnosticReport.conclusionCode",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "CodeableConcept"
}
],
"isModifier" : false,
"isSummary" : false,
"binding" : {
"extension" : [
{
"url" : "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString" : "AdjunctDiagnosis"
}
],
"strength" : "example",
"description" : "Diagnosis codes provided as adjuncts to the report.",
"valueSet" : "http://hl7.org/fhir/ValueSet/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)"
}
]
},
{
"id" : "DiagnosticReport.presentedForm",
"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.",
"comment" : "\"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" : "*",
"base" : {
"path" : "DiagnosticReport.presentedForm",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Attachment"
}
],
"mustSupport" : true,
"isModifier" : false,
"isSummary" : false,
"mapping" : [
{
"identity" : "v2",
"map" : "OBX"
},
{
"identity" : "rim",
"map" : "text (type=ED)"
}
]
}
]
},
"differential" : {
"element" : [
{
"id" : "DiagnosticReport",
"path" : "DiagnosticReport",
"short" : "breastrad-BreastRadiologyReport",
"definition" : "Breast Radiology Diagnostic Report.\n<br>This diagnostic report is the base of the Breast Radiology Report, and contains a summary of the report findings.\n<br>Detailed information about the reports document is contained in the Breast Radiology Document linked to by the [resultComposition] field.",
"mustSupport" : false,
"isModifier" : false,
"isSummary" : false
},
{
"id" : "DiagnosticReport.extension",
"path" : "DiagnosticReport.extension",
"slicing" : {
"id" : "3",
"discriminator" : [
{
"type" : "value",
"path" : "url"
}
],
"ordered" : false,
"rules" : "open"
},
"min" : 1,
"max" : "*"
},
{
"id" : "DiagnosticReport.extension:resultcomposition",
"path" : "DiagnosticReport.extension",
"sliceName" : "resultcomposition",
"definition" : "Reference to the document containing detailed information about the breast radiology report, including assocated sections",
"min" : 1,
"max" : "1",
"base" : {
"path" : "DomainResource.extension",
"min" : 0,
"max" : "*"
},
"type" : [
{
"code" : "Extension",
"profile" : [
"http://hl7.org/fhir/us/breast-radiology/StructureDefinition/breastrad-ResultComposition-extension"
]
}
],
"isModifier" : false,
"isSummary" : false
},
{
"id" : "DiagnosticReport.basedOn",
"path" : "DiagnosticReport.basedOn",
"type" : [
{
"code" : "Reference",
"targetProfile" : [
"http://hl7.org/fhir/StructureDefinition/ServiceRequest",
"http://hl7.org/fhir/us/core/StructureDefinition/us-core-medicationrequest"
]
}
]
},
{
"id" : "DiagnosticReport.category",
"path" : "DiagnosticReport.category",
"min" : 1,
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{
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{
"id" : "DiagnosticReport.category.coding:Fixed_RAD",
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{
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"path" : "DiagnosticReport.category.coding.system",
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},
{
"id" : "DiagnosticReport.category.coding:Fixed_RAD.code",
"path" : "DiagnosticReport.category.coding.code",
"fixedCode" : "RAD"
},
{
"id" : "DiagnosticReport.code",
"path" : "DiagnosticReport.code"
},
{
"id" : "DiagnosticReport.code.coding",
"path" : "DiagnosticReport.code.coding",
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{
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"path" : "CodeableConcept.coding",
"min" : 0,
"max" : "*"
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"type" : [
{
"code" : "Coding"
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{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.system",
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"fixedUri" : "http://loinc.org"
},
{
"id" : "DiagnosticReport.code.coding:Fixed_10193-1.code",
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},
{
"id" : "DiagnosticReport.subject",
"path" : "DiagnosticReport.subject",
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"definition" : "The subject of an observation."
},
{
"id" : "DiagnosticReport.issued",
"path" : "DiagnosticReport.issued",
"min" : 1,
"max" : "1"
},
{
"id" : "DiagnosticReport.performer",
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"type" : [
{
"code" : "Reference",
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"http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization"
]
}
]
},
{
"id" : "DiagnosticReport.resultsInterpreter",
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{
"code" : "Reference",
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]
},
{
"id" : "DiagnosticReport.specimen",
"path" : "DiagnosticReport.specimen",
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"max" : "0"
},
{
"id" : "DiagnosticReport.result",
"path" : "DiagnosticReport.result",
"min" : 0,
"max" : "0",
"type" : [
{
"code" : "Reference",
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}
]
},
{
"id" : "DiagnosticReport.conclusion",
"path" : "DiagnosticReport.conclusion",
"min" : 1,
"max" : "1"
},
{
"id" : "DiagnosticReport.conclusionCode",
"path" : "DiagnosticReport.conclusionCode",
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}
]
}
}
©2019+
Hl7 - Clinical Interoperability Council.
Package hl7.fhir.us.breast-radiology#0.1.0 based on FHIR 4.0.0.
Generated 2019-08-02.
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