International Patient Summary Implementation Guide
1.0.0 - STU 1
International Patient Summary Implementation Guide
1.0.0 - STU 1
This page is part of the International Patient Summary Implementation Guide (v1.0.0: STU 1) based on FHIR R4. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions 
This profile constrains the DiagnosticReport resource to represent diagnostic test and procedure reports in a patient summary.
The official URL for this profile is:
http://hl7.org/fhir/uv/ips/StructureDefinition/DiagnosticReport-uv-ips
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 10 elements
Fixed Value: 1 element
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | S | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
  status | S | 1..1 | code | registered | partial | preliminary | final + Fixed Value: final |
 category | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
  subject | S | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient |
  reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
 effective[x] | S | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]:All Types | Content/Rules for all Types | |||
  data-absent-reason | S | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) |
 effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| performer | S | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service |
| specimen | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on | |
  result | S | 0..* | (Slice Definition) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() |
  result:observation-results | S | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | Observations |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | SI | 0..* | DiagnosticReport | 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 | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business identifier for report |
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!SΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) Fixed Value: final |
| category | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DiagnosticServiceSectionCodes (example) |
| code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCDiagnosticReportCodes (preferred) |
| subject | SΣI | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
| effective[x] | SΣI | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]:All Types | Content/Rules for all Types | |||
 id | 0..1 | string | Unique id for inter-element referencing | |
| data-absent-reason | SI | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Slice: Unordered, Open by value:url Binding: DataAbsentReason (required) |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | SΣI | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| specimen | I | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on |
| result | SI | 0..* | (Slice Definition) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() |
| result:observation-results | SI | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | Observations |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | I | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
This structure is derived from DiagnosticReport
Summary
Mandatory: 4 elements
Must-Support: 10 elements
Fixed Value: 1 element
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 DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | S | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports |
| status | S | 1..1 | code | registered | partial | preliminary | final + Fixed Value: final |
| category | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| code | S | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text |
| subject | S | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient |
| reference | S | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| effective[x] | S | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]:All Types | Content/Rules for all Types | |||
| data-absent-reason | S | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Binding: DataAbsentReason (required) |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| performer | S | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service |
| specimen | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on | |
| result | S | 0..* | (Slice Definition) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() |
| result:observation-results | S | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | Observations |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | SI | 0..* | DiagnosticReport | 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 | ΣI | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | ΣI | 0..* | Identifier | Business identifier for report |
| basedOn | I | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested |
| status | ?!SΣI | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) Fixed Value: final |
| category | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: DiagnosticServiceSectionCodes (example) |
| code | SI | 1..1 | CodeableConceptIPS | Concept - reference to a terminology or just text Binding: LOINCDiagnosticReportCodes (preferred) |
| subject | SΣI | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| reference | SΣI | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | ΣI | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible) |
| identifier | ΣI | 0..1 | Identifier | Logical reference, when literal reference is not known |
| display | ΣI | 0..1 | string | Text alternative for the resource |
| encounter | ΣI | 0..1 | Reference(Encounter) | Health care event when test ordered |
| effective[x] | SΣI | 1..1 | Clinically relevant time/time-period for report | |
| effective[x]:All Types | Content/Rules for all Types | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| data-absent-reason | SI | 0..1 | code | effective[x] absence reason URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason Slice: Unordered, Open by value:url Binding: DataAbsentReason (required) |
| effectiveDateTime | dateTime | |||
| effectivePeriod | Period | |||
| issued | ΣI | 0..1 | instant | DateTime this version was made |
| performer | SΣI | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service |
| resultsInterpreter | ΣI | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
| specimen | I | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on |
| result | SI | 0..* | (Slice Definition) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:$this.resolve() |
| result:observation-results | SI | 0..* | Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) | Observations |
| imagingStudy | I | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report |
| media | ΣI | 0..* | BackboneElement | Key images associated with this report |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| comment | I | 0..1 | string | Comment about the image (e.g. explanation) |
| link | ΣI | 1..1 | Reference(Media) | Reference to the image source |
| conclusion | I | 0..1 | string | Clinical conclusion (interpretation) of test results |
| conclusionCode | I | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example) |
| presentedForm | I | 0..* | Attachment | Entire report as issued |
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
| DiagnosticReport.status | required | Fixed Value: final |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes |
| DiagnosticReport.subject.type | extensible | ResourceType |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| 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.code | 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.subject.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.subject.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | DiagnosticReport.subject.reference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.subject.type | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.subject.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | DiagnosticReport.subject.display | 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.effective[x].extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | DiagnosticReport.effective[x].extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| 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.result:observation-results | 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()) |
IG © 2020+ Health Level Seven International - Patient Care Work Group. Package hl7.fhir.uv.ips#1.0.0 based on FHIR 4.0.1. Generated 2020-05-19
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