The US Core Diagnostic Report Profile is based upon the core FHIR DiagnosticReport Resource and created to meet the 2015 Edition Common Clinical Data Set 'Laboratory test(s) and Laboratory value(s)/result(s)' requirements.
= Must Support, = Is Modifier, = QiCore defined extension
Field | Card. | Type | Description |
---|---|---|---|
locationPerformed | 0..1 | Extension | Facility location where this report was prepared. |
valueReference | 1..1 | QICoreLocation | Value of extension - must be one of a constrained set of the data types (see [Extensibility](http://hl7.org/fhir/extensibility.html) for a list). |
identifier | 0..* | List<Identifier> | Identifiers assigned to this report by the performer or other systems. |
basedOn | 0..* | List<QICoreCarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | QICoreNutritionOrder | QICoreServiceRequest> | Details concerning a service requested. |
status | 1..1 | String | The status of the diagnostic report. Binding: http://hl7.org/fhir/ValueSet/diagnostic-report-status (required) |
category | 1..* | List<Concept> | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Binding: Codes for diagnostic service sections. (example) |
LaboratorySlice | 1..1 | Concept | A code that classifies the clinical discipline, department or diagnostic service that created the report (e.g. cardiology, biochemistry, hematology, MRI). This is used for searching, sorting and display purposes. Binding: Codes for diagnostic service sections. (example) |
code | 1..1 | Concept | The test, panel or battery that was ordered. Binding: LOINC codes (extensible) |
subject | 1..1 | QICorePatient | The subject of the report. Usually, but not always, this is a patient. However, diagnostic services also perform analyses on specimens collected from a variety of other sources. |
encounter | 0..1 | QICoreEncounter | The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about. |
effective[x] | 1..1 | DateTime | Interval<DateTime> | This is the Specimen Collection Datetime or Period which is the physically relevent dateTime for laboratory tests. |
issued | 1..1 | DateTime | The date and time that this version of the report was made available to providers, typically after the report was reviewed and verified. |
performer | 0..* | List<QICorePractitioner | QICoreOrganization> | The diagnostic service that is responsible for issuing the report. |
resultsInterpreter | 0..* | List<QICorePractitioner | QICorePractitionerRole | QICoreOrganization | QICoreCareTeam> | The practitioner or organization that is responsible for the report's conclusions and interpretations. |
specimen | 0..* | List<QICoreSpecimen> | Details about the specimens on which this diagnostic report is based. |
result | 0..* | List<us-core-observation-lab> | [Observations](http://hl7.org/fhir/R4/observation.html) that are part of this diagnostic report. |
imagingStudy | 0..* | List<QICoreImagingStudy> | One or more links to full details of any imaging performed during the diagnostic investigation. Typically, this is imaging performed by DICOM enabled modalities, but this is not required. A fully enabled PACS viewer can use this information to provide views of the source images. |
media | 0..* | List<media> | A list of key images associated with this report. The images are generally created during the diagnostic process, and may be directly of the patient, or of treated specimens (i.e. slides of interest). |
conclusion | 0..1 | String | Concise and clinically contextualized summary conclusion (interpretation/impression) of the diagnostic report. |
conclusionCode | 0..* | List<Concept> | One or more codes that represent the summary conclusion (interpretation/impression) of the diagnostic report. Binding: This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)). (preferred) |
presentedForm | 0..* | List<Attachment> | Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they SHALL be semantically equivalent. |