QI-Core Implementation Guide
4.1.1 - STU 4.1.1
US
This page is part of the Quality Improvement Core Framework (v4.1.1: STU 4) 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
Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note | Version: 4.1.1 | |||
Draft as of 2018-08-22 | 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.
Radiology Diagnostic Report Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
diagnosticReport-locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
value[x]:valueReference | 1..1 | Reference(QICoreLocation) | Value of extension | |
basedOn | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested | |
subject | S | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | S | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Time of the report or note |
issued | S | 0..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICoreObservation) | Observations |
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results |
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
diagnosticReport-locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x]:valueReference | 1..1 | Reference(QICoreLocation) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier for report |
basedOn | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested | |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
category | SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible) |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Time of the report or note | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICoreObservation) | Observations |
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | 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 | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
category | Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible) |
code | Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
subject | Σ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | Σ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | Σ | 1..1 | Time of the report or note | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | Σ | 0..1 | instant | DateTime this version was made |
performer | Σ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
result | 0..* | Reference(QICoreObservation) | Observations | |
imagingStudy | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). | |
presentedForm | 0..* | Attachment | Entire report as issued | |
Documentation for this format |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
diagnosticReport-locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
value[x]:valueReference | 1..1 | Reference(QICoreLocation) | Value of extension | |
basedOn | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested | |
subject | S | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | S | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Time of the report or note |
issued | S | 0..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICoreObservation) | Observations |
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results |
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange | |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
diagnosticReport-locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
id | 0..1 | string | Unique id for inter-element referencing | |
Slices for extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x]:valueReference | 1..1 | Reference(QICoreLocation) | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier for report |
basedOn | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested | |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
category | SΣ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible) |
code | SΣ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Time of the report or note | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICoreObservation) | Observations |
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | 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 | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet |
DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | extensible | USCoreDiagnosticReportCategory |
DiagnosticReport.code | extensible | USCoreDiagnosticreportReportAndNoteCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | Best Practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | DiagnosticReport.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | DiagnosticReport.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | error | DiagnosticReport.extension:locationPerformed | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | DiagnosticReport.extension:locationPerformed | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | error | DiagnosticReport.extension:locationPerformed.value[x]:valueReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | error | DiagnosticReport.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.resultsInterpreter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.specimen | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.result | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.imagingStudy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.media | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.media.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | DiagnosticReport.media.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | error | DiagnosticReport.media.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | error | DiagnosticReport.media.comment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.media.link | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.conclusion | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | error | DiagnosticReport.presentedForm | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |