QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.1)
QI-Core Implementation Guide - This is the current published version.. See the Directory of published versions
| Radiology Diagnostic Report Example |
The official URL for this profile is:
http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note
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.
This profile builds on USCoreDiagnosticReportProfileNoteExchange.
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: 4 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..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
  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..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible) |
| code | ΣI | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note 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 | Time of the report or note | |
| effectiveDateTime | dateTime | |||
 effectivePeriod | Period | |||
| issued | ΣI | 0..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(QICoreObservation) | 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 | SI | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
Summary
Mandatory: 0 element (1 nested mandatory element)
Must-Support: 4 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..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange |
| 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..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible) |
| code | ΣI | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note 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 | Time of the report or note | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..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(QICoreObservation) | 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 | SI | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
| 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 | 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.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()) |
© HL7.org 2011+. (Clinical Quality Improvement WG). hl7.fhir.us.qicore#4.0.0 based on FHIR v4.0.1 Generated 2020-03-24.
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