Cancer Pathology Data Sharing
2.0.0 - STU 2 United States of America flag

This page is part of the Sharing eCC Data from Pathology Labs to EHR (v2.0.0: STU 2) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Pathology Diagnostic Report

Official URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-diagnostic-report Version: 2.0.0
Standards status: Trial-use Maturity Level: 2 Computable Name: USPathologyDiagnosticReport

This DiagnosticReport Profile captures data for a report parsed from an eCP Form.

It is expected that labs will populate dateTimes with the most specific time information known when sending to EHRs (YYYY-MM-DD).

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport USCoreDiagnosticReportProfileNoteExchange
... identifier 0..* Identifier Business identifier for report
... basedOn 0..* Reference(US Pathology Service Request) What was requested
... effective[x] C 0..1 dateTime, Period (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
... resultsInterpreter S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result 0..* Reference(US Pathology Observation) (USCDI) Observations
... presentedForm 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Pathology Related Practitioner Role | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result S 0..* Reference(US Pathology Observation) (USCDI) Observations
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... presentedForm S 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦6.1.0 US Core v6.1
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦6.1.0 US Core v6.1

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10
us-core-10 error DiagnosticReport effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn 0..* Reference(US Pathology Service Request) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Pathology Related Practitioner Role | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result S 0..* Reference(US Pathology Observation) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦6.1.0 US Core v6.1
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦6.1.0 US Core v6.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10
us-core-10 error DiagnosticReport effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport USCoreDiagnosticReportProfileNoteExchange
... identifier 0..* Identifier Business identifier for report
... basedOn 0..* Reference(US Pathology Service Request) What was requested
... effective[x] C 0..1 dateTime, Period (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
... resultsInterpreter S 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result 0..* Reference(US Pathology Observation) (USCDI) Observations
... presentedForm 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Pathology Related Practitioner Role | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result S 0..* Reference(US Pathology Observation) (USCDI) Observations
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... presentedForm S 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦6.1.0 US Core v6.1
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦6.1.0 US Core v6.1

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10
us-core-10 error DiagnosticReport effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn 0..* Reference(US Pathology Service Request) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
Constraints: path-reporting-1
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Pathology Related Practitioner Role | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
... result S 0..* Reference(US Pathology Observation) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
... presentedForm S 1..* Attachment SDC form, HTML render, and/or PDF

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦6.1.0 US Core v6.1
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦6.1.0 US Core v6.1
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error DiagnosticReport If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error 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 error 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 error DiagnosticReport If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DiagnosticReport A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
path-reporting-1 error DiagnosticReport.effective[x] effectiveDateTime SHALL include the month and day $this is DateTime implies $this.toString().length() >= 10
us-core-10 error DiagnosticReport effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

 

Other representations of profile: CSV, Excel, Schematron