QI-Core Implementation Guide
6.0.0-ballot - ballot United States of America flag

This page is part of the Quality Improvement Core Framework (v6.0.0-ballot: STU6 (v6.0.0) Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Resource Profile: QICore DiagnosticReport Profile for Report and Note Exchange

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note Version: 6.0.0-ballot
Active as of 2023-08-01 Computable Name: QICoreDiagnosticReportNote

Profile of DiagnosticReport for Note exchange for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

Usage

See the patterns page for implementation and usage patterns.

Examples

Radiology Diagnostic Report Example

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
... category S1..*CodeableConcept(USCDI) Service category
Slice: Unordered, Open by pattern:$this
... code SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject S1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... effective[x] SΣ0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod S
... issued S0..1instant(USCDI) DateTime this version was made
... performer S0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media S0..*BackboneElement(USCDI) Key images associated with this report

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1code(USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ0..*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 SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(QICore Encounter)(USCDI) Health care event when test ordered
... effective[x] SΣC0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ0..1instant(USCDI) DateTime this version was made
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElement(USCDI) Key images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)(USCDI) Reference to the image source
... presentedForm S0..*Attachment(USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

Constraints

IdGradePath(s)DetailsRequirements
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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[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()
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
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1code(USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConcept(USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*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 SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(QICore Encounter)(USCDI) Health care event when test ordered
... effective[x] SΣC0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod S
... issued SΣ0..1instant(USCDI) DateTime this version was made
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElement(USCDI) Key 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)(USCDI) 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 S0..*Attachment(USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

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
... category S1..*CodeableConcept(USCDI) Service category
Slice: Unordered, Open by pattern:$this
... code SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject S1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... effective[x] SΣ0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod S
... issued S0..1instant(USCDI) DateTime this version was made
... performer S0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media S0..*BackboneElement(USCDI) Key images associated with this report

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

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
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣC1..1code(USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ0..*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 SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(QICore Encounter)(USCDI) Health care event when test ordered
... effective[x] SΣC0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued SΣ0..1instant(USCDI) DateTime this version was made
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElement(USCDI) Key images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)(USCDI) Reference to the image source
... presentedForm S0..*Attachment(USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

Constraints

IdGradePath(s)DetailsRequirements
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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-10errorDiagnosticReporteffective[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

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
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!SΣC1..1code(USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConcept(USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*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 SΣ1..1CodeableConceptQI Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(QICore Patient)(USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(QICore Encounter)(USCDI) Health care event when test ordered
... effective[x] SΣC0..1(USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod S
... issued SΣ0..1instant(USCDI) DateTime this version was made
... performer SΣ0..*Reference(QICore Practitioner | QICore Organization)(USCDI) Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result)(USCDI) Observations
... imagingStudy S0..*Reference(QICore ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElement(USCDI) Key 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)(USCDI) 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 S0..*Attachment(USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron