HL7.FHIR.UV.EYECARE\Ophthalmic OCT Report

HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot

This page is part of the HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1 (v0.1.0: STU1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: Ophthalmic OCT Report

Defining URL:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/diagnostic-report-oct-macula

Version:

0.1.0

Name:

OphthalDiagnosticReportOCTMacula

Title:

Ophthalmic OCT Report

Status:

Draft as of 2021-08-12T15:09:12+00:00

Publisher:

HL7 International - Patient Care WG

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/diagnostic-report-oct-macula

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

Text Summary
Differential Table
Snapshot Table
Snapshot Table (Must Support)
All

This structure is derived from OphthalDiagnosticReport

Summary

Mandatory: 3 elements
Must-Support: 5 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/observation-oct-macula

This structure is derived from OphthalDiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	OphthalDiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
code	S	1..1	CodeableConcept	Name/Code for this diagnostic report
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 57119-0
result	S	0..*	Reference(Observation \| OCT macular observations)	Observations
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	OphthalDiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
id	Σ	0..1	string	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) Max Binding: AllLanguages: 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	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	SΣ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code, value:system
coding:ophthalCode	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 394594003
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 57119-0
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(Patient \| Group \| Device \| Location)	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	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(Observation \| OCT macular observations)	Observations
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	Σ	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	Σ	1..1	Reference(Media)	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		0..*	Attachment	Entire report as issued
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	OphthalDiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
category	Σ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code, value:system
code	Σ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
coding	Σ	1..*	Coding	Code defined by a terminology system
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 57119-0
result		0..*	Reference(Observation \| OCT macular observations)	Observations
Documentation for this format

This structure is derived from OphthalDiagnosticReport

Summary

Mandatory: 3 elements
Must-Support: 5 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

http://hl7.org/fhir/uv/eyecare/StructureDefinition/observation-oct-macula

Differential View

This structure is derived from OphthalDiagnosticReport

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	OphthalDiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
code	S	1..1	CodeableConcept	Name/Code for this diagnostic report
coding	S	1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 57119-0
result	S	0..*	Reference(Observation \| OCT macular observations)	Observations
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DiagnosticReport		0..*	OphthalDiagnosticReport	A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
id	Σ	0..1	string	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) Max Binding: AllLanguages: 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	?!Σ	1..1	code	registered \| partial \| preliminary \| final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report.
category	SΣ	1..*	CodeableConcept	Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:code, value:system
coding:ophthalCode	Σ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	1..1	code	Symbol in syntax defined by the system Fixed Value: 394594003
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
code	SΣ	1..1	CodeableConcept	Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 57119-0
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(Patient \| Group \| Device \| Location)	The subject of the report - usually, but not always, the patient
encounter	Σ	0..1	Reference(Encounter)	Health care event when test ordered
effective[x]	Σ	0..1		Clinically relevant time/time-period for report
effectiveDateTime			dateTime
effectivePeriod			Period
issued	Σ	0..1	instant	DateTime this version was made
performer	Σ	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| CareTeam)	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(Observation \| OCT macular observations)	Observations
imagingStudy		0..*	Reference(ImagingStudy)	Reference to full details of imaging associated with the diagnostic report
media	Σ	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	Σ	1..1	Reference(Media)	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		0..*	Attachment	Entire report as issued
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

Path	Conformance	ValueSet
DiagnosticReport.language	preferred	CommonLanguages Max Binding: AllLanguages
DiagnosticReport.status	required	DiagnosticReportStatus
DiagnosticReport.category	example	DiagnosticServiceSectionCodes
DiagnosticReport.code	preferred	LOINCDiagnosticReportCodes
DiagnosticReport.conclusionCode	example	SNOMEDCTClinicalFindings

Constraints

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.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.category.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	DiagnosticReport.category.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	DiagnosticReport.category.coding	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	DiagnosticReport.category.coding:ophthalCode.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	DiagnosticReport.category.coding:ophthalCode.system	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode.version	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode.display	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.coding:ophthalCode.userSelected	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.category.text	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.code.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	DiagnosticReport.code.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	DiagnosticReport.code.coding	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.coding.extension	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	DiagnosticReport.code.coding.extension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ele-1	DiagnosticReport.code.coding.system	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.coding.version	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.coding.code	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.coding.display	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.coding.userSelected	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ele-1	DiagnosticReport.code.text	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())