# QICore DiagnosticReport Profile for Report and Note Exchange - QI-Core Implementation Guide v7.0.2

* [**Table of Contents**](toc.md)
* [**Artifacts Summary**](artifacts.md)
* **QICore DiagnosticReport Profile for Report and Note Exchange**

## Resource Profile: QICore DiagnosticReport Profile for Report and Note Exchange 

| | | |
| :--- | :--- | :--- |
| *Official URL*:http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note | *Version*:7.0.2 | |
| * Standards status: *[Trial-use](http://hl7.org/fhir/R4/versions.html#std-process) | [Maturity Level](http://hl7.org/fhir/versions.html#maturity): 4 | *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. 

"Must Have", "QI Elements" and "primary code path" are defined in the
[QI-Core Must Support section](index.md#mustsupport-flag).

**Must Have:**
* subject: (QI) The subject of the report - usually, but not always, the patient
* status: (QI)registered | partial | preliminary | final +
* category: (QI) Service Category
* code: (QI) QI-Core Report Code

**QI Elements:**
* effective[x]: (QI) Diagnostically relevant time (typically the time of the procedure)
* result: (QI) Observations
* imagingStudy: (QI) Reference to full details of imaging associated with the diagnostic report
* issued: (QI) DateTime this version was made
* media: (QI) Key images associated with this report
* encounter: (QI) Health care event when test ordered
* performer: (QI) Responsible Diagnostic Service

**Primary code path:**code

(PCPath) This element is the primary code path for this resource
[CQL Retrieve](https://cql.hl7.org/02-authorsguide.html#retrieve)

**Usage** 
  See the [patterns](patterns.md) page for implementation and usage patterns.  

### Examples

 

| |
| :--- |
| [Radiology Diagnostic Report Example](DiagnosticReport-note-example.md) |

 

**Usages:**

* Refer to this Profile: [QICore ImagingStudy](StructureDefinition-qicore-imagingstudy.md), [QICore Procedure](StructureDefinition-qicore-procedure.md) and [QICore ServiceRequest](StructureDefinition-qicore-servicerequest.md)
* Examples for this Profile: [DiagnosticReport/note-example](DiagnosticReport-note-example.md)

You can also check for [usages in the FHIR IG Statistics](https://packages2.fhir.org/xig/hl7.fhir.us.qicore|current/StructureDefinition/qicore-diagnosticreport-note)

### Formal Views of Profile Content

 [Description of Profiles, Differentials, Snapshots and how the different presentations work](http://build.fhir.org/ig/FHIR/ig-guidance/readingIgs.html#structure-definitions). 

 

Other representations of profile: [CSV](StructureDefinition-qicore-diagnosticreport-note.csv), [Excel](StructureDefinition-qicore-diagnosticreport-note.xlsx), [Schematron](StructureDefinition-qicore-diagnosticreport-note.sch) 



## Resource Content

```json
{
  "resourceType" : "StructureDefinition",
  "id" : "qicore-diagnosticreport-note",
  "extension" : [{
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-modelInfo-primaryCodePath",
    "valueString" : "code"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-modelInfo-isIncluded",
    "valueBoolean" : true
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-modelInfo-isRetrievable",
    "valueBoolean" : true
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/cqf-modelInfo-label",
    "valueString" : "DiagnosticReportNote"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
    "valueCode" : "cqi"
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
    "valueInteger" : 4,
    "_valueInteger" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/qicore/ImplementationGuide/us-qicore"
      }]
    }
  },
  {
    "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
    "valueCode" : "trial-use",
    "_valueCode" : {
      "extension" : [{
        "url" : "http://hl7.org/fhir/StructureDefinition/structuredefinition-conformance-derivedFrom",
        "valueCanonical" : "http://hl7.org/fhir/us/qicore/ImplementationGuide/us-qicore"
      }]
    }
  }],
  "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note",
  "version" : "7.0.2",
  "name" : "QICoreDiagnosticReportNote",
  "title" : "QICore DiagnosticReport Profile for Report and Note Exchange",
  "status" : "active",
  "experimental" : false,
  "date" : "2023-08-01",
  "publisher" : "HL7 International / Clinical Quality Information",
  "contact" : [{
    "name" : "Clinical Quality Information WG",
    "telecom" : [{
      "system" : "url",
      "value" : "http://www.hl7.org/Special/committees/cqi"
    }]
  }],
  "description" : "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.",
  "jurisdiction" : [{
    "coding" : [{
      "system" : "urn:iso:std:iso:3166",
      "code" : "US"
    }]
  }],
  "fhirVersion" : "4.0.1",
  "mapping" : [{
    "identity" : "workflow",
    "uri" : "http://hl7.org/fhir/workflow",
    "name" : "Workflow Pattern"
  },
  {
    "identity" : "v2",
    "uri" : "http://hl7.org/v2",
    "name" : "HL7 v2 Mapping"
  },
  {
    "identity" : "rim",
    "uri" : "http://hl7.org/v3",
    "name" : "RIM Mapping"
  },
  {
    "identity" : "w5",
    "uri" : "http://hl7.org/fhir/fivews",
    "name" : "FiveWs Pattern Mapping"
  }],
  "kind" : "resource",
  "abstract" : false,
  "type" : "DiagnosticReport",
  "baseDefinition" : "http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note",
  "derivation" : "constraint",
  "differential" : {
    "element" : [{
      "id" : "DiagnosticReport",
      "path" : "DiagnosticReport"
    },
    {
      "id" : "DiagnosticReport.status",
      "path" : "DiagnosticReport.status",
      "short" : "(QI)registered | partial | preliminary | final +",
      "definition" : "The status of the diagnostic report.",
      "requirements" : "Diagnostic services routinely issue provisional/incomplete reports, and sometimes withdraw previously released reports.",
      "min" : 1,
      "max" : "1",
      "base" : {
        "path" : "DiagnosticReport.status",
        "min" : 1,
        "max" : "1"
      },
      "type" : [{
        "code" : "code"
      }],
      "condition" : ["us-core-8", "us-core-9"],
      "mustSupport" : true,
      "isModifier" : true,
      "isModifierReason" : "This element is labeled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
      "isSummary" : true,
      "binding" : {
        "strength" : "required",
        "valueSet" : "http://hl7.org/fhir/ValueSet/diagnostic-report-status"
      },
      "mapping" : [{
        "identity" : "workflow",
        "map" : "Event.status"
      },
      {
        "identity" : "w5",
        "map" : "FiveWs.status"
      },
      {
        "identity" : "v2",
        "map" : "OBR-25 (not 1:1 mapping)"
      },
      {
        "identity" : "rim",
        "map" : "statusCode  Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type \"revise\""
      }]
    },
    {
      "id" : "DiagnosticReport.category",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.category",
      "slicing" : {
        "discriminator" : [{
          "type" : "pattern",
          "path" : "$this"
        }],
        "rules" : "open"
      },
      "short" : "(QI) Service Category",
      "min" : 1
    },
    {
      "id" : "DiagnosticReport.code",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.code",
      "short" : "(QI) QI-Core Report Code",
      "definition" : "The test, panel, report, or note that was ordered.",
      "comment" : "The typical patterns for codes are:  1)  a LOINC code either as a translation from a \"local\" code or as a primary code, or 2)  a local code only if no suitable LOINC exists,  or 3)  both the local and the LOINC translation.   Systems SHALL be capable of sending the local code if one exists.",
      "alias" : ["Type"],
      "min" : 1,
      "max" : "1",
      "base" : {
        "path" : "DiagnosticReport.code",
        "min" : 1,
        "max" : "1"
      },
      "type" : [{
        "code" : "CodeableConcept"
      }],
      "isModifier" : false,
      "isSummary" : true,
      "binding" : {
        "strength" : "extensible",
        "description" : "LOINC codes",
        "valueSet" : "http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes"
      }
    },
    {
      "id" : "DiagnosticReport.subject",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.subject",
      "short" : "(QI) The subject of the report - usually, but not always, the patient",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient"]
      }]
    },
    {
      "id" : "DiagnosticReport.encounter",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.encounter",
      "short" : "(QI) Health care event when test ordered",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter"]
      }]
    },
    {
      "id" : "DiagnosticReport.effective[x]",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.effective[x]",
      "short" : "(QI) Diagnostically relevant time (typically the time of the procedure)",
      "min" : 0,
      "max" : "1",
      "base" : {
        "path" : "DiagnosticReport.effective[x]",
        "min" : 0,
        "max" : "1"
      },
      "type" : [{
        "extension" : [{
          "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
          "valueBoolean" : true
        }],
        "code" : "dateTime"
      },
      {
        "extension" : [{
          "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
          "valueBoolean" : true
        }],
        "code" : "Period"
      }],
      "isModifier" : false,
      "isSummary" : true
    },
    {
      "id" : "DiagnosticReport.issued",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.issued",
      "short" : "(QI) DateTime this version was made"
    },
    {
      "id" : "DiagnosticReport.performer",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.performer",
      "short" : "(QI) Responsible Diagnostic Service",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner",
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization"]
      }]
    },
    {
      "id" : "DiagnosticReport.result",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.result",
      "short" : "(QI) Observations",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-lab",
        "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-clinical-result"]
      }]
    },
    {
      "id" : "DiagnosticReport.imagingStudy",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.imagingStudy",
      "short" : "(QI) Reference to full details of imaging associated with the diagnostic report",
      "type" : [{
        "code" : "Reference",
        "targetProfile" : ["http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-imagingstudy"]
      }]
    },
    {
      "id" : "DiagnosticReport.media",
      "extension" : [{
        "url" : "http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-keyelement",
        "valueBoolean" : true
      }],
      "path" : "DiagnosticReport.media",
      "short" : "(QI) Key images associated with this report"
    }]
  }
}

```
