This page is part of the Quality Improvement Core Framework (v5.0.0: STU5 (v5.0.0)) based on FHIR R4. The current version which supercedes this version is 4.1.1. 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: 5.0.0 | |||
Active as of 2022-07-01 | 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.
Radiology Diagnostic Report Example |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension |
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |
category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | S | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient |
encounter | S | 0..1 | Reference(QICore Encounter) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period S | |||
issued | S | 0..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations |
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | S | 0..* | BackboneElement | Key images associated with this 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 |
Path | Conformance | ValueSet |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) |
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(QICore Encounter) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations |
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 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 |
Path | Conformance | ValueSet |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-10 | error | DiagnosticReport | effective[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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
id | Σ | 0..1 | id | 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): 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 | |||||
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 | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |||||
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(QICore Encounter) | Health care event when test ordered | ||||
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period S | |||||||
issued | SΣ | 0..1 | instant | DateTime this version was made | ||||
performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations | ||||
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | ||||
media | SΣ | 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 | SΣ | 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 |
Path | Conformance | ValueSet | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes | ||||
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements (1 nested mandatory element)
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension |
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |
category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | S | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient |
encounter | S | 0..1 | Reference(QICore Encounter) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period S | |||
issued | S | 0..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations |
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | S | 0..* | BackboneElement | Key images associated with this 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 |
Path | Conformance | ValueSet |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
locationPerformed | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed | |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) |
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient |
encounter | SΣ | 0..1 | Reference(QICore Encounter) | Health care event when test ordered |
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service |
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations |
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | SΣ | 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 |
Path | Conformance | ValueSet |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory |
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes |
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | 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 | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-10 | error | DiagnosticReport | effective[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
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | USCoreDiagnosticReportProfileNoteExchange | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | ||||
id | Σ | 0..1 | id | 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): 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 | |||||
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 | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed" | |||||
value[x]:valueReference | S | 1..1 | Reference(QICore Location) | Value of extension | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(QICore CarePlan | QICore ImmunizationRecommendation | QICore MedicationRequest | QICore NutritionOrder | QICore ServiceRequest) | What was requested | |||||
status | ?!SΣC | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Service category Binding: US Core Diagnostic Report Category Codes (required) | ||||
code | SΣ | 1..1 | CodeableConcept | QI Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
subject | SΣ | 1..1 | Reference(QICore Patient) | The subject of the report - usually, but not always, the patient | ||||
encounter | SΣ | 0..1 | Reference(QICore Encounter) | Health care event when test ordered | ||||
effective[x] | SΣC | 0..1 | Diagnostically relevant time (typically the time of the procedure) | |||||
effectiveDateTime | dateTime S | |||||||
effectivePeriod | Period S | |||||||
issued | SΣ | 0..1 | instant | DateTime this version was made | ||||
performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(QICore Specimen) | Specimens this report is based on | |||||
result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Test Result | QICore Observation Imaging Result) | Observations | ||||
imagingStudy | S | 0..* | Reference(QICore ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | ||||
media | SΣ | 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 | SΣ | 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 |
Path | Conformance | ValueSet | ||||
DiagnosticReport.language | preferred | CommonLanguages
| ||||
DiagnosticReport.status | required | DiagnosticReportStatus | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodes | ||||
DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategory | ||||
DiagnosticReport.code | extensible | USCoreNonLaboratoryCodes | ||||
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements (1 nested mandatory element)
Must-Support: 13 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron