Cancer Pathology Data Sharing
1.0.0 - STU1 United States of America flag

This page is part of the Sharing eCC Data from Pathology Labs to EHR (v1.0.0: STU 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Pathology Diagnostic Report

Official URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-diagnostic-report Version: 1.0.0
Active as of 2023-07-11 Computable Name: USPathologyDiagnosticReport

Copyright/Legal:

It is expected that labs will populate dateTimes with the most specific time information known when sending to EHRs (YYYY-MM-DD).

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... subject 1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... effective[x] SC0..1dateTime S, PeriodDiagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
... resultsInterpreter S0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile)Observations
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

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()
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..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 S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
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()
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... subject 1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... effective[x] SC0..1dateTime S, PeriodDiagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
... resultsInterpreter S0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA 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
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile)Observations
... media SΣ0..*BackboneElementKey images associated with this report
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... link SΣ1..1Reference(Media)Reference to the image source
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes

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()
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C0..*USCoreDiagnosticReportProfileNoteExchangeA 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(US Pathology Service Request)What was requested
... status ?!SΣC1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣC0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*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 SΣ1..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 S0..*AttachmentEntire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
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()
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10

 

Other representations of profile: CSV, Excel, Schematron