US Core (R4) Implementation Guide STU 3 Ballot

This page is part of the US Core (v2.1.0: STU3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

This is a ballot version of the USCore Implementation Guide. The current version is STU 2. See the Directory of published versions

StructureDefinition-new-us-core-diagnosticreport

This profile sets minimum expectations for searching and fetching Diagnostic Reports and Notes using the DiagnosticReport resource. It is built independent of the US Core DiagnosticReport lab profile for initial testing. When US Core is balloted for R4 it may be merged into the existing profile. This profile identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the DiagnosticReport when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Diagnostic Report profile:

  • Query for a specific Radiology note (e.g. 84178-3 Interventional Radiology Note)
  • Query for category of reports (e.g. all Cardiology reports)
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Diagnostic Report must have:

  1. a status
  2. a category of the DiagnosticReport
  3. a code describing the type of report
  4. a patient
  5. date and time the report was created
  6. an author (actor) producing the report

In addition it should have (if available):

  1. the encounter the report occurred within
  2. instant the report was released
  3. an image
  4. a referene to the full report (presentedForm)

Profile specific implementation guidance:

The DiagnosticReport.category binding must support at a minimum the 3 concepts of Cardiology, Radiology, and Pathology. Other categories may be supported.

Examples
  • TBD

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/core/StructureDefinition/new-us-core-diagnosticreport

Published on Tue Apr 10 23:48:14 AEST 2018 as a active by .

This profile builds on DiagnosticReport

Summary of the Mandatory Requirements
...todo...
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*New US Core Diagnostic Report Profile
... 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)
... 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..*CodeableConceptService category
Binding: US Core DiagnosticReport Category Codes Value Set (extensible)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: LOINCDiagnosticReportCodes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodTime of the report or note
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*New US Core Diagnostic Report Profile
... 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)
... 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..*CodeableConceptService category
Binding: US Core DiagnosticReport Category Codes Value Set (extensible)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: LOINCDiagnosticReportCodes (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodTime of the report or note
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result 0..*Reference(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), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

GET [base]/DiagnosticReport?patient=[id]&category=[system]|[code]

Example: GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5

Support: Mandatory to support search by patient and category codes specified in Argonaut DiagnosticReport Category Codes.

Implementation Notes: Search based on diagnostic report category code, for example Radiology (LP29684-5). This fetches a bundle of all LP29684-5 related DiagnosticReport resources for the specified patient (how to search by reference) and (how to search by token).

GET [base]/DiagnosticReport?patient=[id]&code=[LOINC{,LOINC2,LOINC3,...}]

Example: GET [base]/DiagnosticReport?patient=1032702&code=84178-3 (LOINC = 84178-3 Interventional Radiology Note)

Support: Mandatory support search by a specific DiagnosticReport code. SHOULD support search by multiple report codes.

Implementation Notes: Search based on DiagnosticReport code(s). This fetches a bundle of all DiagnosticReport resources for a specific diagnostic order code(s) for the specified patient (how to search by reference) and (how to search by token).

GET [base]/DiagnosticReport?patient=[id]&category=[system]|[code]&date=[date]{&date=[date]}

Example: GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5&date=ge2010-01-14

Support: Mandatory support search by category codes in Argonaut DiagnosticReport Category Codes and date or period.

Implementation Notes: Search based on category code, for example Radiology (LP29684-5), and date. This fetches a bundle of all DiagnosticReport resources with category LP29684-5 for the specified patient for a specified time period (how to search by reference), (how to search by token) and (how to search by date).