This page is part of the MCC eCare Plan Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/MCCDiagnosticReportAndNote | Version: 1.0.0 | |||
Active as of 2024-08-13 | Computable Name: MCCDiagnosticReportAndNote |
This profile constrains US Core Diagnostic Report and Note for use in the MCC FHIR Care Plan or other FHIR Care Plans.
This profile sets additional expectations for the US Core Diagnostic Report and Note Profile to search and fetch Diagnostic Reports and Notes using the DiagnosticReport resource. Diagnostic Reports are typically used for Cardiology, Radiology, and Pathology reports. In addition to the requirements set forth in US Core Diagnostic Report and Note, this derived profile is designed to add requirements to the following elements:
This profile can be bound with any of the value sets found on US Core Diagnostic Report profile or the MCC Diagnostic Report and Note Imaging Value Sets library page to query for, fetch or record imaging procedure results as defined in the scope of each value set. Additional codes and value sets are not precluded.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
code | 1..1 | CodeableConcept | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. 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) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | (USCDI) Responsible Diagnostic Service |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) | (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 | 0..* | Attachment | (USCDI) Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. 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) | |||||
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 Core PractitionerRole Profile | US Core CareTeam Profile) | (USCDI) Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | 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 | 0..* | Attachment | (USCDI) Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
code | 1..1 | CodeableConcept | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. 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) | |
effectiveDateTime | dateTime | |||
issued | SΣ | 0..1 | instant | (USCDI) DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile) | (USCDI) Responsible Diagnostic Service |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) | (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 | 0..* | Attachment | (USCDI) Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainesToGoal | S | 0..* | Reference(Goal) | The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources. URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | 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 | Please see the Diagnostic Report and Note Imaging Value Set Library for Imaging realted value sets that are derived from LOINC that can be used at DiagnosticReport.code element. Other use cases beyond Imaging have yet to have value sets assigned, and are not precluded. 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) | |||||
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 Core PractitionerRole Profile | US Core CareTeam Profile) | (USCDI) Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | 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 | 0..* | Attachment | (USCDI) Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
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() | |
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() |
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