Vital Records Medicolegal Death Investigation (MDI) FHIR Implementation Guide
2.0.0-ballot - ballot United States of America flag

This page is part of the Medicolegal Death Investigation (MDI) (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: DiagnosticReport - Toxicology Lab Result to MDI

Official URL: http://hl7.org/fhir/us/mdi/StructureDefinition/DiagnosticReport-toxicology-to-mdi Version: 2.0.0-ballot
Active as of 2024-04-05 Computable Name: DiagnosticReportToxicologyToMDI
Other Identifiers: OID:2.16.840.1.113883.4.642.40.11.42.4

This profile contains constraints to the US Core Diagnostic Report Profile to address the use case for sending data from a forensic toxicology laboratory information management system to an MDI information management system. Each analyzed specimen, represented by a Specimen - Toxicology Lab resource, must be referenced by at least one Observation - Toxicology Lab Result and may be referenced by more than one Observation - Toxicology Lab Result. For specimens received but not analyzed, the laboratory should provide a reason for no analysis in the DiagnosticReport.conclusion and/or each unanalyzed specimen’s Specimen - Toxicology Lab Specimen.note.

Usage:

Changes since version true:

  • No changes

    • Formal Views of Profile Content

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

    This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport USCoreDiagnosticReportProfileLaboratoryReporting
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... subject 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... performer 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Responsible Diagnostic Service
    ... result 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

    doco Documentation for this format
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    us-core-9: issued 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
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by pattern:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



    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/v2-0074
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: LAB
    ... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
    Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
    .... effectiveDateTime dateTime
    ... issued SΣC 0..1 instant When the report was released
    ... performer SΣ 0..* Reference(US Core Practitioner Profile) Responsible Diagnostic Service
    ... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
    ... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    us-core-9: issued 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
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by pattern:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



    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/v2-0074
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: LAB
    ...... 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 SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
    Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued SΣC 0..1 instant When the report was released
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile) Responsible Diagnostic Service
    ... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
    ... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
    ... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
    ... media Σ 0..* BackboneElement 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 Σ 1..1 Reference(Media) Reference to the image source
    ... conclusion S 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 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DiagnosticReport.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
    DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
    http://hl7.org/fhir/ValueSet/clinical-findings
    from the FHIR Standard

    Differential View

    This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport USCoreDiagnosticReportProfileLaboratoryReporting
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... subject 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... performer 0..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) Responsible Diagnostic Service
    ... result 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

    doco Documentation for this format

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    us-core-9: issued 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
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by pattern:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



    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/v2-0074
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: LAB
    ... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
    Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
    .... effectiveDateTime dateTime
    ... issued SΣC 0..1 instant When the report was released
    ... performer SΣ 0..* Reference(US Core Practitioner Profile) Responsible Diagnostic Service
    ... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
    ... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    us-core-9: issued 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
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
    URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by pattern:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



    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/v2-0074
    ...... version 0..1 string Version of the system - if relevant
    ...... code 1..1 code Symbol in syntax defined by the system
    Fixed Value: LAB
    ...... 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 SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
    Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the diagnostic report is the decedent.
    ... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued SΣC 0..1 instant When the report was released
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile) Responsible Diagnostic Service
    ... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
    ... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
    ... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
    ... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
    ... media Σ 0..* BackboneElement 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 Σ 1..1 Reference(Media) Reference to the image source
    ... conclusion S 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 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DiagnosticReport.languagepreferredCommonLanguages
    Additional Bindings Purpose
    AllLanguages Max Binding
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
    DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
    http://hl7.org/fhir/ValueSet/clinical-findings
    from the FHIR Standard

     

    Other representations of profile: CSV, Excel, Schematron