International Patient Summary Implementation Guide
1.1.0 - STU 1 Update 1 International flag

This page is part of the International Patient Summary Implementation Guide (v1.1.0: STU 1) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

Resource Profile: DiagnosticReport (IPS)

Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/DiagnosticReport-uv-ips Version: 1.1.0
Standards status: Trial-use Maturity Level: 2 Computable Name: DiagnosticReportUvIps

This profile constrains the DiagnosticReport resource to represent diagnostic test and procedure reports in a patient summary.

This profile constrains the DiagnosticReport resource to use the specific IPS profiles for observations and coded data types.

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1coderegistered | partial | preliminary | final +
Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
.... reference S1..1stringLiteral reference, Relative, internal or absolute URL
... effective[x] S1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.

.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... performer S0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... reference SΣC1..1stringLiteral reference, Relative, internal or absolute URL
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredFixed Value: final
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredFixed Value: final
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.subject.typeextensibleResourceType
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1coderegistered | partial | preliminary | final +
Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
.... reference S1..1stringLiteral reference, Relative, internal or absolute URL
... effective[x] S1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.

.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... performer S0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... reference SΣC1..1stringLiteral reference, Relative, internal or absolute URL
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.statusrequiredFixed Value: final
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*DiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... category S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S1..1CodeableConceptIPSConcept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ1..1Reference(Patient (IPS) | Group)The subject of the report - usually, but not always, the patient
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC1..1stringLiteral reference, Relative, internal or absolute URL
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] SΣ1..1Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1stringUnique id for inter-element referencing
..... Slices for extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... data-absent-reason S0..1codeeffective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required): Used to specify why the normally expected content of the data element is missing.


.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer SΣ0..*Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen (IPS))Specimens this report is based on
... Slices for result S0..*Reference(Observation)Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S0..*Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS))Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredFixed Value: final
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
DiagnosticReport.subject.typeextensibleResourceType
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron