PACIO Personal Functioning and Engagement Implementation Guide
1.0.0 - STU1 United States of America flag

This page is part of the PACIO Personal Functioning and Engagement Implementation Guide (v1.0.0: STU 1) 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: Personal Functioning and Engagement Narrative History of Status

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-narrative-history-of-status Version: 1.0.0
Draft as of 2024-01-05 Computable Name: PFENarrativeHistoryOfStatus

An exchange of a narrative summary regarding the most recent prior status immediately preceding the current admission, illness, or exacerbation for a patient. The use of this profile is encouraged in the absence of formal prior level assessments. For formal assessments conducted with for example, an assessment instrument, use the collection and single observation profiles defined in this IG to capture assessment data.

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

  • Query for a narrative of a patient’s prior functioning and engagement.
  • Record or update prior functioning and engagement narratives for a Patient.

Mandatory and Must Support Data Elements

The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with 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 Personal Functioning and Engagement Narrative History of Status must have:

  1. a status
  2. a category code of “functioning”
  3. a code describing the type of narrative
  4. a patient
  5. the point in time or period covered by the narrative
  6. who wrote the narrative
  7. a narrative about the patient’s prior functioning and engagement

Each Personal Functioning and Engagement Narrative History of Status must support:

  1. the location the narrative was written
  2. the level of assistance required by the patient during the time or period covered by the narrative
  3. an additional category value(s) specifying the specific health or health-related domain that this narrative is related to*
  4. the encounter the report occurred within
  5. instant the report was released

* see guidance below

Profile specific implementation guidance:

  • *When a health or health-related domain is specified as an additional category value, DiagnosticReport.code SHOULD be drawn from the corresponding domain-based value set as discussed on the domains page.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptAn extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... category 1..*CodeableConceptService category
... category:functioning S1..1CodeableConceptService category
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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
..... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... category:PFEDomain S0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... effective[x] 1..1dateTime, PeriodDiagnostically relevant time (typically the time of the procedure)
... performer 1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... presentedForm 1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ1..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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
.... category:PFEDomain SΣ0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... 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] SΣC1..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ1..*Reference(US Core Practitioner Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... result S0..*Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile)Observations
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... presentedForm S1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:functioningexamplePattern: functioning("Functioning")
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA 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
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptAn extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 ?!SΣC1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:PFEDomain SΣ0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... 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] SΣC1..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ1..*Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..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): Diagnosis codes provided as adjuncts to the report.


... presentedForm S1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:functioningexamplePattern: functioning("Functioning")
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptAn extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... category 1..*CodeableConceptService category
... category:functioning S1..1CodeableConceptService category
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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
..... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
... category:PFEDomain S0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... effective[x] 1..1dateTime, PeriodDiagnostically relevant time (typically the time of the procedure)
... performer 1..*Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... presentedForm 1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ1..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://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
.... category:PFEDomain SΣ0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... 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] SΣC1..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ1..*Reference(US Core Practitioner Profile | US Core Organization Profile)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... result S0..*Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile)Observations
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... presentedForm S1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:functioningexamplePattern: functioning("Functioning")
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA 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
... event-location S0..1Reference(US Core Location Profile)An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S0..1CodeableConceptAn extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 ?!SΣC1..1codeShould have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ1..1CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
...... id0..1stringUnique id for inter-element referencing
...... extension0..*ExtensionAdditional content defined by implementations
...... system1..1uriIdentity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version0..1stringVersion of the system - if relevant
...... code1..1codeSymbol in syntax defined by the system
Fixed Value: functioning
...... display1..1stringRepresentation defined by the system
Fixed Value: Functioning
...... userSelected0..1booleanIf this coding was chosen directly by the user
..... text0..1stringPlain text representation of the concept
.... category:PFEDomain SΣ0..*CodeableConceptService category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... 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] SΣC1..1Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ1..*Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S)The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..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): Diagnosis codes provided as adjuncts to the report.


... presentedForm S1..*AttachmentThe narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.category:functioningexamplePattern: functioning("Functioning")
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

 

Other representations of profile: CSV, Excel, Schematron

Notes:

The syntax used to describe the interactions below is described here.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching using the combination of the patient and category search parameters:

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

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code = mental_functions (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and code search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&code=http://loinc.org|11332-4
    2. GET [base]/DiagnosticReport?patient=1134281&code=http://loinc.org|11332-4,http://loinc.org|10158-4

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and code(s). SHOULD support search by multiple report codes. The DiagnosticReport code parameter searches `DiagnosticReport.code only. (how to search by reference and how to search by token)

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]DiagnosticReport?patient=555580&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&date=ge2018-03-14T00:00:00Z

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code = mental_functions (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&status=final

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and category mental_functions and status final (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and code and date search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]DiagnosticReport?patient=555580&code=http://loinc.org|11332-4&date=ge2019-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)