Release 4B Ballot #1

This page is part of the FHIR Specification v4.1.0: R4B Ballot. About the R4B version of FHIR. The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R4B R4 R3

Orders and Observations Work Group Maturity Level: 0Trial Use Use Context: Not yet ready for Production use

The official URL for this profile is:

http://hl7.org/fhir/StructureDefinition/diagnosticreport-genetics

Describes how the DiagnosticReport resource is used to report structured genetic test results

This profile was published on Sat, May 12, 2012 00:00+1000 as a draft by Grahame Grieve.

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

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
... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
Max Binding: All Languages: IETF language tag

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReport-geneticsAssessedCondition 0..*Reference(Condition)AssessedCondition
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAssessedCondition
... DiagnosticReport-geneticsFamilyMemberHistory 0..*Reference(FamilyMemberHistory)FamilyHistory
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsFamilyMemberHistory
... DiagnosticReport-geneticsAnalysis 0..*(Complex)Analysis
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAnalysis
... DiagnosticReport-geneticsReferences 0..*(Complex)References
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsReferences
... 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.

... category Σ0..*CodeableConceptService category
Binding: Diagnostic Service Section Codes (example): HL7 V2 table 0074


... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred): LOINC Codes for Diagnostic Reports

... subject Σ0..1Reference(Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*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(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1idUnique 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
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format
<!-- DiagnosticReport-Genetics -->doco

<DiagnosticReport xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- ?? 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- ?? 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- ?? 0..1 Language of the resource content   -->
 <text><!-- ?? 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource 
     Contained, inline Resources --></contained>
 <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- ?? 0..* Identifier 
     Business identifier for report --></identifier>
 <basedOn><!-- ?? 0..* Reference(CarePlan) What was requested --></basedOn>
 <status value="[code]"/><!-- ?? 1..1 registered | partial | preliminary | final +   -->
 <category><!-- ?? 0..* CodeableConcept Service category   --></category>
 <code><!-- ?? 1..1 CodeableConcept Name/Code for this diagnostic report   --></code>
 <subject><!-- ?? 0..1 Reference(Patient) 
     The subject of the report - usually, but not always, the patient --></subject>
 <encounter><!-- ?? 0..1 Reference(Encounter) 
     Health care event when test ordered --></encounter>
 <effective[x]><!-- ?? 0..1 dateTime|Period 
     Clinically relevant time/time-period for report --></effective[x]>
 <issued value="[instant]"/><!-- ?? 0..1 DateTime this version was made -->
 <performer><!-- ?? 0..* Reference(Practitioner) 
     Responsible Diagnostic Service --></performer>
 <resultsInterpreter><!-- ?? 0..* Reference(Practitioner) 
     Primary result interpreter --></resultsInterpreter>
 <specimen><!-- ?? 0..* Reference(Specimen) 
     Specimens this report is based on --></specimen>
 <result><!-- ?? 0..* Reference(Observation) Observations --></result>
 <imagingStudy><!-- ?? 0..* Reference(ImagingStudy) 
     Reference to full details of imaging associated with the diagnostic report --></imagingStudy>
 <media> ?? 0..* BackboneElement  <!-- ?? 0..* Key images associated with this report -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <comment value="[string]"/><!-- ?? 0..1 Comment about the image (e.g. explanation) -->
  <link><!-- ?? 1..1 Reference(Media) 
      Reference to the image source --></link>
 </media>
 <conclusion value="[string]"/><!-- ?? 0..1 Clinical conclusion (interpretation) of test results -->
 <conclusionCode><!-- ?? 0..0 CodeableConcept Codes for the clinical conclusion of test results   --></conclusionCode>
 <presentedForm><!-- ?? 0..* Attachment 
     Entire report as issued --></presentedForm>
</DiagnosticReport>
{ // DiagnosticReport-Genetics
  // from Element: extension
    "meta" : { Meta }, // C?Metadata about the resource
    "implicitRules" : "<uri>", // C?A set of rules under which this content was created
    "language" : "<code>", // C?Language of the resource content
    "text" : { Narrative }, // C?Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "extension" : [ //  sliced by value:url  in the specified order, Open 
      { // AssessedCondition // C?
        // from Element: extension
      },
      { // FamilyHistory // C?
        // from Element: extension
      },
      { // Analysis // C?
        // from Element: extension
      },
      { // References // C?
        // from Element: extension
      }
    ],
    "modifierExtension" : [{ Extension }], // C?Extensions that cannot be ignored
    "identifier" : [{ Identifier }], // C?Business identifier for report
    "basedOn" : [{ Reference(CarePlan) }], // C?What was requested
    "status" : "<code>", // C? R! registered | partial | preliminary | final +
    "category" : [{ CodeableConcept }], // C?Service category
    "code" : { CodeableConcept }, // C? R! Name/Code for this diagnostic report
    "subject" : { Reference(Patient) }, // C?The subject of the report - usually, but not always, the patient
    "encounter" : { Reference(Encounter) }, // C?Health care event when test ordered
// value[x]: Clinically relevant time/time-period for report. One of these 2:
    "effectiveDateTime" : "<dateTime>", // C?Clinically relevant time/time-period for report
    "effectivePeriod" : { Period }, // C?Clinically relevant time/time-period for report
    "issued" : "<instant>", // C?DateTime this version was made
    "performer" : [{ Reference(Practitioner) }], // C?Responsible Diagnostic Service
    "resultsInterpreter" : [{ Reference(Practitioner) }], // C?Primary result interpreter
    "specimen" : [{ Reference(Specimen) }], // C?Specimens this report is based on
    "result" : [{ Reference(Observation) }], // C?Observations
    "imagingStudy" : [{ Reference(ImagingStudy) }], // C?Reference to full details of imaging associated with the diagnostic report
    "media" : [{ BackboneElement }], // C?Key images associated with this report
    "conclusion" : "<string>", // C?Clinical conclusion (interpretation) of test results
    "presentedForm" : [{ Attachment }], // C?Entire report as issued
  }

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
... language 0..1codeLanguage of the resource content
Binding: Common Languages (preferred)
Max Binding: All Languages: IETF language tag

... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... DiagnosticReport-geneticsAssessedCondition 0..*Reference(Condition)AssessedCondition
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAssessedCondition
... DiagnosticReport-geneticsFamilyMemberHistory 0..*Reference(FamilyMemberHistory)FamilyHistory
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsFamilyMemberHistory
... DiagnosticReport-geneticsAnalysis 0..*(Complex)Analysis
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsAnalysis
... DiagnosticReport-geneticsReferences 0..*(Complex)References
URL: http://hl7.org/fhir/StructureDefinition/DiagnosticReport-geneticsReferences
... 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.

... category Σ0..*CodeableConceptService category
Binding: Diagnostic Service Section Codes (example): HL7 V2 table 0074


... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred): LOINC Codes for Diagnostic Reports

... subject Σ0..1Reference(Patient | Group | Device | Location | Organization | Procedure | Practitioner | Medication | Substance)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*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(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*BackboneElementKey images associated with this report
.... id 0..1idUnique 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
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

XML Template

<!-- DiagnosticReport-Genetics -->doco

<DiagnosticReport xmlns="http://hl7.org/fhir"
>
  <!-- from Element: extension -->
 <id value="[id]"/><!-- 0..1 Logical id of this artifact -->
 <meta><!-- ?? 0..1 Meta Metadata about the resource --></meta>
 <implicitRules value="[uri]"/><!-- ?? 0..1 A set of rules under which this content was created -->
 <language value="[code]"/><!-- ?? 0..1 Language of the resource content   -->
 <text><!-- ?? 0..1 Narrative 
     Text summary of the resource, for human interpretation --></text>
 <contained><!-- 0..* Resource 
     Contained, inline Resources --></contained>
 <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored  --></modifierExtension>
 <identifier><!-- ?? 0..* Identifier 
     Business identifier for report --></identifier>
 <basedOn><!-- ?? 0..* Reference(CarePlan) What was requested --></basedOn>
 <status value="[code]"/><!-- ?? 1..1 registered | partial | preliminary | final +   -->
 <category><!-- ?? 0..* CodeableConcept Service category   --></category>
 <code><!-- ?? 1..1 CodeableConcept Name/Code for this diagnostic report   --></code>
 <subject><!-- ?? 0..1 Reference(Patient) 
     The subject of the report - usually, but not always, the patient --></subject>
 <encounter><!-- ?? 0..1 Reference(Encounter) 
     Health care event when test ordered --></encounter>
 <effective[x]><!-- ?? 0..1 dateTime|Period 
     Clinically relevant time/time-period for report --></effective[x]>
 <issued value="[instant]"/><!-- ?? 0..1 DateTime this version was made -->
 <performer><!-- ?? 0..* Reference(Practitioner) 
     Responsible Diagnostic Service --></performer>
 <resultsInterpreter><!-- ?? 0..* Reference(Practitioner) 
     Primary result interpreter --></resultsInterpreter>
 <specimen><!-- ?? 0..* Reference(Specimen) 
     Specimens this report is based on --></specimen>
 <result><!-- ?? 0..* Reference(Observation) Observations --></result>
 <imagingStudy><!-- ?? 0..* Reference(ImagingStudy) 
     Reference to full details of imaging associated with the diagnostic report --></imagingStudy>
 <media> ?? 0..* BackboneElement  <!-- ?? 0..* Key images associated with this report -->
  <modifierExtension><!-- ?? 0..* Extension  Extensions that cannot be ignored even if unrecognized  --></modifierExtension>
  <comment value="[string]"/><!-- ?? 0..1 Comment about the image (e.g. explanation) -->
  <link><!-- ?? 1..1 Reference(Media) 
      Reference to the image source --></link>
 </media>
 <conclusion value="[string]"/><!-- ?? 0..1 Clinical conclusion (interpretation) of test results -->
 <conclusionCode><!-- ?? 0..0 CodeableConcept Codes for the clinical conclusion of test results   --></conclusionCode>
 <presentedForm><!-- ?? 0..* Attachment 
     Entire report as issued --></presentedForm>
</DiagnosticReport>

JSON Template

{ // DiagnosticReport-Genetics
  // from Element: extension
    "meta" : { Meta }, // C?Metadata about the resource
    "implicitRules" : "<uri>", // C?A set of rules under which this content was created
    "language" : "<code>", // C?Language of the resource content
    "text" : { Narrative }, // C?Text summary of the resource, for human interpretation
    "contained" : [{ Resource }], //Contained, inline Resources
    "extension" : [ //  sliced by value:url  in the specified order, Open 
      { // AssessedCondition // C?
        // from Element: extension
      },
      { // FamilyHistory // C?
        // from Element: extension
      },
      { // Analysis // C?
        // from Element: extension
      },
      { // References // C?
        // from Element: extension
      }
    ],
    "modifierExtension" : [{ Extension }], // C?Extensions that cannot be ignored
    "identifier" : [{ Identifier }], // C?Business identifier for report
    "basedOn" : [{ Reference(CarePlan) }], // C?What was requested
    "status" : "<code>", // C? R! registered | partial | preliminary | final +
    "category" : [{ CodeableConcept }], // C?Service category
    "code" : { CodeableConcept }, // C? R! Name/Code for this diagnostic report
    "subject" : { Reference(Patient) }, // C?The subject of the report - usually, but not always, the patient
    "encounter" : { Reference(Encounter) }, // C?Health care event when test ordered
// value[x]: Clinically relevant time/time-period for report. One of these 2:
    "effectiveDateTime" : "<dateTime>", // C?Clinically relevant time/time-period for report
    "effectivePeriod" : { Period }, // C?Clinically relevant time/time-period for report
    "issued" : "<instant>", // C?DateTime this version was made
    "performer" : [{ Reference(Practitioner) }], // C?Responsible Diagnostic Service
    "resultsInterpreter" : [{ Reference(Practitioner) }], // C?Primary result interpreter
    "specimen" : [{ Reference(Specimen) }], // C?Specimens this report is based on
    "result" : [{ Reference(Observation) }], // C?Observations
    "imagingStudy" : [{ Reference(ImagingStudy) }], // C?Reference to full details of imaging associated with the diagnostic report
    "media" : [{ BackboneElement }], // C?Key images associated with this report
    "conclusion" : "<string>", // C?Clinical conclusion (interpretation) of test results
    "presentedForm" : [{ Attachment }], // C?Entire report as issued
  }

 

Alternate definitions: Master Definition (XML, JSON), Schematron

PathNameConformanceValueSet
DiagnosticReport.languageCommon LanguagespreferredCommon Languages
DiagnosticReport.statusDiagnosticReportStatusrequiredDiagnosticReportStatus
DiagnosticReport.categoryDiagnostic Service Section CodesexampleDiagnostic Service Section Codes
DiagnosticReport.codeLOINC Diagnostic Report CodespreferredLOINC Diagnostic Report Codes
.