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

DiagnosticReport

 

The official URL for this profile is: 

http://hl7.org/fhir/us/breast-radiology/StructureDefinition/obf-DiagnosticReport

The findings and interpretation of diagnostic tests performed on patients, groups of patients, devices, and locations, and/or specimens derived from these. The report includes clinical context such as requesting and provider information, and some mix of atomic results, images, textual and coded interpretations, and formatted representation of diagnostic reports.

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 (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Mapping Source

This structure represents the following mapping definition:

obf.DiagnosticReport 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 I0..*obf-DiagnosticReport
... 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 0..*ExtensionAdditional content defined by implementations
... 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)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
... 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
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(obf-Observation)Observations
... 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 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes 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 (2 nested mandatory elements)

Structures

This structure refers to these other structures:

Mapping Source

This structure represents the following mapping definition:

obf.DiagnosticReport 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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*obf-DiagnosticReport
... 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 0..*ExtensionAdditional content defined by implementations
... 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)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
... 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
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(obf-Observation)Observations
... 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 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes 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())