Breast Radiology Reporting - 1st STU ballot
0.2.0 - STU 1 Ballot 2020May
Breast Radiology Reporting - 1st STU ballot
0.2.0 - STU 1 Ballot 2020May
Breast Radiology Reporting - 1st STU ballot - Local Development build (v0.2.0). See the Directory of published versions
Breast Radiology Diagnostic Report
This resource is one of the components of a Breast Radiology Document. Each Breast Radiology Document bundle will contain exactly one Breast Radiology Document instance that is referenced in the document’s ‘Report’ section.
This instance will contain the top level results of the exam, including the narrative result.
This resource is a profile of the FHIR DiagnosticReport base resource.
The official URL for this profile is:
http://hl7.org/fhir/us/breast-radiology/StructureDefinition/BreastRadReport
Graphical Overview
This graph provides an overview of how and where this resource is referenced.
Click on any of the elements of the graph to go to a section describing that element.
Profile Fragments
The following are the fragments that are included in this profile.
This section is included primarily for developers to understand the hierarchy and commonality of each profile.
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 1 element
Prohibited: 2 elements
Slices
This structure defines the following Slices:
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | Breast Radiology Diagnostic Report | |
  category | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by type:$this | |
   category:categoryImaging | 1..1 | CodeableConcept | Service category Required Pattern: At least the following | |
   coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
 code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Required Pattern: At least the following | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10193-1 | |
| specimen | 0..0 | |||
| result | 0..0 | |||
| conclusion | 1..1 | string | Clinical conclusion (interpretation) of test results | |
| conclusionCode | S | 1..1 | CodeableConcept | Codes for the clinical conclusion of test results Binding: BiRads(r) Assessment Category ValueSet (required) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | I | 0..* | DiagnosticReport | Breast Radiology Diagnostic Report |
 id | Σ | 0..1 | string | Logical id of this artifact |
 meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
 extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business identifier for report |
 basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| category | ΣI | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by type:$this Binding: DiagnosticServiceSectionCodes (example) |
| category:categoryImaging | ΣI | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example) Required Pattern: At least the following |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
 coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
 text | 0..1 | string | Plain text representation of the concept | |
| code | ΣI | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10193-1 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| subject | ΣI | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
 effective[x] | ΣI | 0..1 | Clinically relevant time/time-period for report | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 1..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | SI | 1..1 | CodeableConcept | Codes for the clinical conclusion of test results Binding: BiRads(r) Assessment Category ValueSet (required) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 1 element
Prohibited: 2 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | Breast Radiology Diagnostic Report | |
| category | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by type:$this | |
| category:categoryImaging | 1..1 | CodeableConcept | Service category Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
| code | 1..1 | CodeableConcept | Name/Code for this diagnostic report Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10193-1 | |
| specimen | 0..0 | |||
| result | 0..0 | |||
| conclusion | 1..1 | string | Clinical conclusion (interpretation) of test results | |
| conclusionCode | S | 1..1 | CodeableConcept | Codes for the clinical conclusion of test results Binding: BiRads(r) Assessment Category ValueSet (required) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | I | 0..* | DiagnosticReport | Breast Radiology Diagnostic Report |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business identifier for report |
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| category | ΣI | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by type:$this Binding: DiagnosticServiceSectionCodes (example) |
| category:categoryImaging | ΣI | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/observation-category | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: imaging | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | ΣI | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10193-1 | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| subject | ΣI | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
| effective[x] | ΣI | 0..1 | Clinically relevant time/time-period for report | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 1..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | SI | 1..1 | CodeableConcept | Codes for the clinical conclusion of test results Binding: BiRads(r) Assessment Category ValueSet (required) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.category:categoryImaging | example | Pattern: imaging |
| DiagnosticReport.code | preferred | Pattern: LOINC code 10193-1 |
| DiagnosticReport.conclusionCode | required | BiRadsAssessmentCategoriesVS |
| Id | Path | Details | Requirements |
| dom-2 | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | DiagnosticReport | 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 : 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-4 | DiagnosticReport | If 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-5 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | DiagnosticReport.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | DiagnosticReport.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | DiagnosticReport.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.category:categoryImaging | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.resultsInterpreter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.imagingStudy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.media | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.media.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.media.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | DiagnosticReport.media.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | DiagnosticReport.media.comment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.media.link | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.conclusion | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.presentedForm | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2019+ Hl7 - Clinical Interoperability Council. Package hl7.fhir.us.breast-radiology#0.2.0 based on FHIR 4.0.1. Generated 2020-04-07
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