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The official URL for this profile is:
http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-lab
Profile of DiagnosticReport for laboratory results for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.
This profile builds on USCoreDiagnosticReportProfileLaboratoryReporting.
This profile was published on Wed Aug 22 00:00:00 UTC 2018 as a draft by Health Level Seven, Inc. - CQI WG.
Description of Profiles, Differentials, and Snapshots.
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | I | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | ΣI | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
diagnosticReport-locationPerformed | I | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..0 | ||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x] | I | 1..1 | (Slice Definition) | Value of extension Slice: Unordered, Closed by type:$this |
value[x]:valueReference | I | 1..1 | Reference(QICoreLocation) | Value of extension |
modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
identifier | ΣI | 0..* | Identifier | Business identifier for report |
basedOn | I | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested |
status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
category | SΣI | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example) |
category:LaboratorySlice | SΣI | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example) Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | ΣI | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible) |
subject | ΣI | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | ΣI | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | ΣI | 1..1 | Specimen Collection Datetime or Period | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | ΣI | 1..1 | instant | DateTime this version was made |
performer | ΣI | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | I | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on |
result | SI | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
imagingStudy | SI | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | ΣI | 0..* | BackboneElement | Key images associated with this report |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
conclusion | SI | 0..1 | string | Clinical conclusion (interpretation) of test results |
conclusionCode | SI | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred) |
presentedForm | I | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | I | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
id | Σ | 0..1 | string | Logical id of this artifact |
meta | ΣI | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
contained | 0..* | Resource | Contained, inline Resources | |
extension | I | 0..* | Extension | Extension Slice: Unordered, Open by value:url |
diagnosticReport-locationPerformed | I | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..0 | ||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x] | I | 1..1 | (Slice Definition) | Value of extension Slice: Unordered, Closed by type:$this |
value[x]:valueReference | I | 1..1 | Reference(QICoreLocation) | Value of extension |
modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
identifier | ΣI | 0..* | Identifier | Business identifier for report |
basedOn | I | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested |
status | ?!ΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
category | SΣI | 1..* | (Slice Definition) | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example) |
category:LaboratorySlice | SΣI | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example) Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | ΣI | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible) |
subject | ΣI | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient |
encounter | ΣI | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered |
effective[x] | ΣI | 1..1 | Specimen Collection Datetime or Period | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | ΣI | 1..1 | instant | DateTime this version was made |
performer | ΣI | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service |
resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | I | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on |
result | SI | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
imagingStudy | SI | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | ΣI | 0..* | BackboneElement | Key images associated with this report |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | I | 0..* | Extension | Additional content defined by implementations |
modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
conclusion | SI | 0..1 | string | Clinical conclusion (interpretation) of test results |
conclusionCode | SI | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred) |
presentedForm | I | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet / Code |
DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:LaboratorySlice | example | Pattern: LAB |
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Path | Details | Requirements |
dom-2 | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | 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 | 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 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | DiagnosticReport.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | DiagnosticReport.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | DiagnosticReport.extension:locationPerformed | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | DiagnosticReport.extension:locationPerformed | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | DiagnosticReport.extension:locationPerformed.value[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.extension:locationPerformed.value[x]:valueReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | DiagnosticReport.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.category:LaboratorySlice | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.resultsInterpreter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.specimen | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.result | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.imagingStudy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.media | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.media.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | DiagnosticReport.media.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | DiagnosticReport.media.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
ele-1 | DiagnosticReport.media.comment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.media.link | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.conclusion | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ele-1 | DiagnosticReport.presentedForm | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |