Medicolegal Death Investigation (MDI)
1.0.0 - STU 1 US

This page is part of the Medicolegal Death Investigation (MDI) (v1.0.0: STU 1) based on FHIR 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: DiagnosticReport - Toxicology Lab Result to MDI

Official URL: http://hl7.org/fhir/us/mdi/StructureDefinition/DiagnosticReport-toxicology-to-mdi Version: 1.0.0
Active as of 2022-09-30 Computable Name: DiagnosticReportToxicologyToMDI

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:

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 0..*USCoreDiagnosticReportProfileLaboratoryReportingA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... extension-tracking-numbers S0..*IdentifierA 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
... identifier S0..*IdentifierBusiness identifier for report
... subject S1..1Reference(US Core Patient Profile)The subject of the diagnostic report is the decedent.
... performer S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Responsible Diagnostic Service
... specimen S0..*Reference(Specimen - Toxicology Lab)The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S0..*Reference(Observation - Toxicology Lab Result)The toxicology lab analysis results being reported.
... conclusion S0..1stringClinical conclusion (interpretation) of test results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileLaboratoryReportingA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-tracking-numbers S0..*IdentifierA 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..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the diagnostic report is the decedent.
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣC0..1instantWhen the report was released
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(Specimen - Toxicology Lab)The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S0..*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 Σ0..*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 S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileLaboratoryReportingA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... extension-tracking-numbers 0..*IdentifierA 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
... identifier Σ0..*IdentifierBusiness identifier for report
... status ?!ΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:LaboratorySlice Σ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
... code Σ1..1CodeableConceptUS Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject Σ1..1Reference(US Core Patient Profile)The subject of the diagnostic report is the decedent.
... effective[x] ΣC0..1Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTimedateTime
... issued ΣC0..1instantWhen the report was released
... performer Σ0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Responsible Diagnostic Service
... specimen 0..*Reference(Specimen - Toxicology Lab)The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result 0..*Reference(Observation - Toxicology Lab Result)The toxicology lab analysis results being reported.
... conclusion 0..1stringClinical conclusion (interpretation) of test results

doco Documentation for this format

Differential View

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileLaboratoryReportingA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... extension-tracking-numbers S0..*IdentifierA 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
... identifier S0..*IdentifierBusiness identifier for report
... subject S1..1Reference(US Core Patient Profile)The subject of the diagnostic report is the decedent.
... performer S0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Responsible Diagnostic Service
... specimen S0..*Reference(Specimen - Toxicology Lab)The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S0..*Reference(Observation - Toxicology Lab Result)The toxicology lab analysis results being reported.
... conclusion S0..1stringClinical conclusion (interpretation) of test results

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileLaboratoryReportingA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... extension-tracking-numbers S0..*IdentifierA 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..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1idUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1idUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: LAB
...... display0..1stringRepresentation defined by the system
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
... code SΣ1..1CodeableConceptUS Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the diagnostic report is the decedent.
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣC0..1instantWhen the report was released
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(Specimen - Toxicology Lab)The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S0..*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 Σ0..*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 S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePathDetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6Best PracticeDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
us-core-8errorDiagnosticReporteffective[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()
us-core-9errorDiagnosticReportissued 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 issued.exists()
ele-1errorDiagnosticReport.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.extension:extension-tracking-numbersAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.extension:extension-tracking-numbersMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category:LaboratorySliceAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.effective[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.issuedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.resultsInterpreterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.specimenAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.resultAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.imagingStudyAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.media.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.media.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.media.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.media.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.media.commentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.media.linkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.conclusionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.conclusionCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.presentedFormAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())