QI-Core Implementation Guide
6.0.0 - STU6
QI-Core Implementation Guide
6.0.0 - STU6
This page is part of the Quality Improvement Core Framework (v6.0.0: STU6 (v6.0.0)) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. 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: 6.0.0 | |||
| Active as of 2023-08-01 | 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 | USCoreDiagnosticReportProfileNoteExchange | |||
  category | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this | |
 code | Σ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
 subject | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | |
| encounter | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered | |
  effective[x] | Σ | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
  effectiveDateTime | dateTime | |||
 effectivePeriod | Period | |||
 issued | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made | |
| performer | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service | |
| result | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations | |
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |
| media | 0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
| 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 us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| Slices for category | SΣ | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
  category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
| code | SΣ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered |
| effective[x] | SΣC | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
| effectiveDateTime | dateTime | |||
| issued | SΣ | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made |
| performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
| result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |
| media | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
| presentedForm | S | 0..* | Attachment | (USCDI) Entire report as issued |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusfrom the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
| 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 us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
| 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 | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
| Slices for category | SΣ | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
| code | SΣ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | ||||
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered | ||||
| effective[x] | SΣC | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |||||
| effectiveDateTime | dateTime S | |||||||
| effectivePeriod | Period | |||||||
| issued | SΣ | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made | ||||
| performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations | ||||
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |||||
| media | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (USCDI) Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | S | 0..* | Attachment | (USCDI) Entire report as issued | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusfrom the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
| 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() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | USCoreDiagnosticReportProfileNoteExchange | |||
| category | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this | |
| code | Σ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
| subject | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | |
| encounter | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered | |
| effective[x] | Σ | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made | |
| performer | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service | |
| result | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations | |
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |
| media | 0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
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 us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
| Slices for category | SΣ | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
| code | SΣ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes |
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient |
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered |
| effective[x] | SΣC | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |
| effectiveDateTime | dateTime | |||
| issued | SΣ | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made |
| performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service |
| result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations |
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |
| media | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) Key images associated with this report |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| link | SΣ | 1..1 | Reference(Media) | (USCDI) Reference to the image source |
| presentedForm | S | 0..* | Attachment | (USCDI) Entire report as issued |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusfrom the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | |
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | |
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes |
| 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 us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' | ||||
| 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 | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
| status | ?!SΣC | 1..1 | code | (USCDI) registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) | ||||
| Slices for category | SΣ | 1..* | CodeableConcept | (QI-Core)(USCDI) Service Category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| category:us-core | SΣ | 0..* | CodeableConcept | (USCDI) Service category Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
| code | SΣ | 1..1 | CodeableConcept | (QI-Core)(USCDI) QI-Core Report Code Binding: US Core Non Laboratory Codes (extensible): LOINC codes | ||||
| subject | SΣ | 1..1 | Reference(QICore Patient) | (QI-Core)(USCDI) The subject of the report - usually, but not always, the patient | ||||
| encounter | SΣ | 0..1 | Reference(QICore Encounter) | (QI-Core)(USCDI) Health care event when test ordered | ||||
| effective[x] | SΣC | 0..1 | (QI-Core)(USCDI) Diagnostically relevant time (typically the time of the procedure) | |||||
| effectiveDateTime | dateTime S | |||||||
| effectivePeriod | Period | |||||||
| issued | SΣ | 0..1 | instant | (QI-Core)(USCDI) DateTime this version was made | ||||
| performer | SΣ | 0..* | Reference(QICore Practitioner | QICore Organization) | (QI-Core)(USCDI) Responsible Diagnostic Service | ||||
| resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
| specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
| result | S | 0..* | Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) | (QI-Core)(USCDI) Observations | ||||
| imagingStudy | 0..* | Reference(QICore ImagingStudy) | (QI-Core) Reference to full details of imaging associated with the diagnostic report | |||||
| media | SΣ | 0..* | BackboneElement | (QI-Core)(USCDI) 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) | (USCDI) Reference to the image source | ||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
| presentedForm | S | 0..* | Attachment | (USCDI) Entire report as issued | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusfrom the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsfrom the FHIR Standard | ||||
| DiagnosticReport.category:us-core | required | USCoreDiagnosticReportCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category | ||||
| DiagnosticReport.code | extensible | USCoreNonLaboratoryCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes | ||||
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findingsfrom the FHIR Standard |
| 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() |
This structure is derived from USCoreDiagnosticReportProfileNoteExchange
Summary
Mandatory: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2019+ HL7 International / Clinical Quality Information. Package hl7.fhir.us.qicore#6.0.0 based on FHIR 4.0.1. Generated 2024-03-01
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