This page is part of the FHIRcast (v3.0.0-ballot: STU3 (v3.0.0) Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/fhir/uv/fhircast/StructureDefinition/fhircast-diagnostic-report-open | Version: 3.0.0-ballot | |||
Draft as of 2024-04-10 | Computable Name: FHIRcastDiagnosticReportOpen |
Provides guidance as to which DiagnosticReport attributes should be present and considerations as to how each attribute should be valued in all [FHIR resource]-open events.
At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request.
Typically the report is associated with an order from an information system. In this case the accession number of the order is provided in the DiagnosticReport’s basedOn
array attribute as a reference using a ServiceRequest reference type and the “ACSN” identifier type. The accession number SHALL be included as a business identifier if it is known.
A reporting system may also include its own identifier and should use an appropriate identifier type and system when supplying such a business identifier.
In radiology reports or other image related uses of FHIRcast, at least one imaging study would likely be the subject of the report and included in the event’s context. In this case, the reference to one or more ImagingStudy resources would be provided.
FHIR R4 versus FHIR R5
In the FHIR R4 DiagnosticReport resource image study references would be placed in the imagingStudy
attribute. In a FHIR R5 (or above) DiagnosticReport this attribute has been renamed study
since the allowed reference types has been expanded to include references to GenomicStudy resources. This is obviously a breaking change.
In FHIRcast deployments based on FHIR R5, the attribute study
SHALL be used rather than the imagingStudy
attribute.
Additionally FHIR R5 includes a supportingInfo
attribute. While not yet formally provided for in FHIR R5, it has been recommended that the next release of FHIR allow an ImagingStudy reference be included in this attribute so that the DiagnosticReport could indicate one or more image studies were consulted during the creation of the report. As such in FHIR R5 deployments, this field is considered labeled as must support.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element |
id | 1..1 | id | A logical id of the resource SHALL be provided. | |
identifier | S | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). |
status | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR | |
subject | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport | |
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this report | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element |
id | Σ | 1..1 | id | A logical id of the resource SHALL be provided. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). |
status | ?!Σ | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
subject | Σ | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport |
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this report | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | |
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() | |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element | ||||
id | Σ | 1..1 | id | A logical id of the resource SHALL be provided. | ||||
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 | SΣ | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). | ||||
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). | ||||
status | ?!Σ | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
subject | Σ | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport | ||||
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 | 0..* | Reference(Observation) | Observations | |||||
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this 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 |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() | |
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() |
This structure is derived from DiagnosticReport
Differential View
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element |
id | 1..1 | id | A logical id of the resource SHALL be provided. | |
identifier | S | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). |
status | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR | |
subject | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport | |
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this report | |
Documentation for this format |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element |
id | Σ | 1..1 | id | A logical id of the resource SHALL be provided. |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). |
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). |
status | ?!Σ | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR Binding: DiagnosticReportStatus (required): The status of the diagnostic report. |
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
subject | Σ | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport |
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this report | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | |
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() | |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports business-identifier: identifier array or basedOn array SHALL contain at least one element | ||||
id | Σ | 1..1 | id | A logical id of the resource SHALL be provided. | ||||
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 | SΣ | 0..* | Identifier | A business identifier of the DiagnosticReport may be provided as part of the [FHIR resource]-open request (see detailed description). | ||||
basedOn | S | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | At least one business identifier of the DiagnosticReport SHALL be provided in a [FHIR resource]-open request (see detailed description). | ||||
status | ?!Σ | 1..1 | code | Status of the DiagnosticReport, note this may not be known and hence have a value of `unknown`; however, is included since it is required by FHIR Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
subject | Σ | 1..1 | Reference(FHIRcast Patient for Open Events) | Reference to the Patient resource associated with the DiagnosticReport | ||||
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 | 0..* | Reference(Observation) | Observations | |||||
imagingStudy | 0..* | Reference(FHIRcast ImagingStudy for Open Events) | Imaging study (or studies) which are the subject of this 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 |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1 from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
business-identifier | error | DiagnosticReport | identifier array or basedOn array SHALL contain at least one element : identifier.exists() or basedOn.exists() | |
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() |
This structure is derived from DiagnosticReport
Other representations of profile: CSV, Excel, Schematron