Current Build

This page is part of the C-CDA on FHIR Implementation Guide (v1.8.0: STU 1 Ballot 2) based on FHIR v1.8.0. The current version which supercedes this version is 1.1.0. For a full list of available versions, see the Directory of published versions

D.4.1 StructureDefinition: CCDA-on-FHIR-Diagnostic-Imaging

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Diagnostic-Imaging

A Diagnostic Imaging Report (DIR) is a document that contains a consulting specialists interpretation of image data. It conveys the interpretation to the referring (ordering) physician and becomes part of the patients medical record. It is for use in Radiology, Endoscopy, Cardiology, and other imaging specialties.

This profile builds on C-CDA on FHIR US Realm Header.

This profile was published on Thu Dec 08 06:39:19 AEDT 2016 as a draft by Lantana Consulting Group.

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

Example for: C-CDA on FHIR Diagnostic Imaging.

This structure is derived from C-CDA on FHIR US Realm Header

Summary

Mandatory: 5 elements (+4 nested mandatory elements)

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptDiagnostic Imaging Report
Binding: LOINC Imaging Document Codes (preferred)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementFindings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
.... text 1..1Narrativetext
... section 0..1BackboneElementDICOM Object Catalog Section - DCM 121181
.... title 1..1stringtitle
.... code 1..1CodeableConceptDicom Object Catalog
Required Pattern: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text 1..1Narrativetext
... section 0..*BackboneElementsection
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: DIRSectionTypeCodes (preferred)
.... text 0..1Narrativetext

doco Documentation for this format

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConceptDiagnostic Imaging Report
Binding: LOINC Imaging Document Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I1..1BackboneElementFindings Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos2
Nested Section
... section I0..1BackboneElementDICOM Object Catalog Section - DCM 121181
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDicom Object Catalog
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos3
Nested Section
... section I0..*BackboneElementsection
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: DIRSectionTypeCodes (preferred)
.... text I0..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos4
Nested Section

doco Documentation for this format

This structure is derived from C-CDA on FHIR US Realm Header

Summary

Mandatory: 5 elements (+4 nested mandatory elements)

Slices

This structure defines the following Slices:

  • The element Composition.section is sliced based on the value of Composition.section.code

Differential View

This structure is derived from C-CDA on FHIR US Realm Header

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*
... type 1..1CodeableConceptDiagnostic Imaging Report
Binding: LOINC Imaging Document Codes (preferred)
... section BackboneElementSlice: Unordered, Open, by Composition.section.code
... section 1..1BackboneElementFindings Section
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
.... text 1..1Narrativetext
... section 0..1BackboneElementDICOM Object Catalog Section - DCM 121181
.... title 1..1stringtitle
.... code 1..1CodeableConceptDicom Object Catalog
Required Pattern: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text 1..1Narrativetext
... section 0..*BackboneElementsection
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: DIRSectionTypeCodes (preferred)
.... text 0..1Narrativetext

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*A set of resources composed into a single coherent clinical statement with clinical attestation
... id ∑0..1idLogical id of this artifact
... meta ∑0..1MetaMetadata about the resource
... implicitRules ?!∑0..1uriA set of rules under which this content was created
... language 1..1codelanguage
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension ExtensionExtension
Slice: Unordered, Open, by Composition.url
... CCDA-on-FHIR-Data-Enterer 0..1Reference(US Core Practitioner)dataEnterer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Data-Enterer
... CCDA-on-FHIR-Informant 0..*Reference(US Core Practitioner)informant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Informant
... CCDA-on-FHIR-Information-Recipient 0..*Reference(US Core Practitioner)informationRecipient
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Information-Recipient
... CCDA-on-FHIR-Participant 0..*Reference(RelatedPerson)participant
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Participant
... CCDA-on-FHIR-Performer 0..*Reference(US Core Practitioner)performer
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Performer
... CCDA-on-FHIR-Authorization 0..*Reference(C-CDA on FHIR Consent)authorization
URL: http://hl7.org/fhir/ccda/StructureDefinition/CCDA-on-FHIR-Authorization
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier ∑1..1Identifieridentifier
... date ∑1..1dateTimedate
... type ∑1..1CodeableConceptDiagnostic Imaging Report
Binding: LOINC Imaging Document Codes (preferred)
... class ∑0..1CodeableConceptCategorization of Composition
Binding: FHIR Document Class Codes (example)
... title ∑1..1stringDocument Title
... status ?!∑1..1codestatus
Binding: CompositionStatus (required)
... confidentiality ?!∑1..1codeconfidentiality
Binding: ConfidentialityClassification (required)
... subject ∑1..1Reference(US Core Patient Profile)recordTarget
... author ∑1..*Reference(US Core Practitioner), Reference(Device)author
... attester ∑IBackboneElementAttests to accuracy of composition
Slice: Unordered, Open, by Composition.attester.mode
... attester ∑I0..1BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..1codemode
Binding: CompositionAttestationMode (required)
Required Pattern: legal
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... attester ∑I0..*BackboneElementattester
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... mode ∑1..*codemode
Binding: CompositionAttestationMode (required)
.... time ∑0..1dateTimeWhen composition attested
.... party ∑0..1Reference(US Core Practitioner)party
... custodian ∑1..1Reference(US Core Organization Profile)custodian
... event ∑I0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... code ∑0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ∑0..1PeriodThe period covered by the documentation
.... detail ∑0..*Reference(Resource)The event(s) being documented
... encounter ∑0..1Reference(Encounter)Context of the Composition
... section IBackboneElementComposition is broken into sections
Slice: Unordered, Open, by Composition.section.code
... section I1..1BackboneElementFindings Section
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptcode
Binding: Document Section Codes (example)
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos2
Nested Section
... section I0..1BackboneElementDICOM Object Catalog Section - DCM 121181
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 1..1stringtitle
.... code 1..1CodeableConceptDicom Object Catalog
Binding: Document Section Codes (example)
Required Pattern: {"coding":[{"system":"urn:oid:1.2.840.10008.2.16.4","code":"121181"}]}
.... text I1..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos3
Nested Section
... section I0..*BackboneElementsection
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!∑0..*ExtensionExtensions that cannot be ignored
.... title 0..1stringtitle
.... code 1..1CodeableConceptcode
Binding: DIRSectionTypeCodes (preferred)
.... text I0..1Narrativetext
.... mode ?!∑0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy 0..1CodeableConceptOrder of section entries
Binding: List Order Codes (preferred)
.... entry I0..*Reference(Resource)A reference to data that supports this section
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: List Empty Reasons (preferred)
.... section I0..*Unknown reference to #Composition:c-cdaonfhirdiagnosticimaging.section:section_slice_pos4
Nested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON, CSV), Schema: XML Schematron

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
Composition.languageCommon LanguagesextensibleCommon Languages
Composition.typeLOINC Imaging Document CodespreferredLOINC Imaging Document Codes
Composition.classFHIR Document Class CodesexampleFHIR Document Class Codes
Composition.statusCompositionStatusrequiredCompositionStatus
Composition.confidentialityConfidentialityClassificationrequiredConfidentialityClassification
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.attester.modeCompositionAttestationModerequiredCompositionAttestationMode
Composition.event.codev3 Code System ActCodeexamplev3 Code System ActCode
Composition.section.codeDIRSectionTypeCodespreferredDIRSectionTypeCodes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDIRSectionTypeCodespreferredDIRSectionTypeCodes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons
Composition.section.codeDIRSectionTypeCodespreferredDIRSectionTypeCodes
Composition.section.modeListModerequiredListMode
Composition.section.orderedByList Order CodespreferredList Order Codes
Composition.section.emptyReasonList Empty ReasonspreferredList Empty Reasons

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2CompositionIf the resource is contained in another resource, it SHALL NOT contain nested Resources
XPath: not(parent::f:contained and f:contained)
dom-1CompositionIf the resource is contained in another resource, it SHALL NOT contain any narrative
XPath: not(parent::f:contained and f:text)
dom-4CompositionIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
XPath: not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
dom-3CompositionIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
XPath: not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.attesterAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.eventAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
ele-1Composition.sectionAll FHIR elements must have a @value or children
XPath: @value|f:*|h:div
cmp-1Composition.sectionA section must at least one of text, entries, or sub-sections
XPath: exists(f:text) or exists(f:entry) or exists(f:section)
cmp-2Composition.sectionA section can only have an emptyReason if it is empty
XPath: not(exists(f:emptyReason) and exists(f:entry))
.