This page is part of the US Core (v4.0.0: STU4) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions
Defining URL: | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab |
Version: | 4.0.0 |
Name: | USCoreDiagnosticReportProfileLaboratoryReporting |
Title: | US Core DiagnosticReport Profile for Laboratory Results Reporting |
Status: | Active as of 2019-05-21 |
Definition: | Defines constraints and extensions on the DiagnosticReport resource for the minimal set of data to query and retrieve diagnostic reports associated with laboratory results for a patient |
Publisher: | HL7 International - US Realm Steering Committee |
Copyright: | Used by permission of HL7 International, all rights reserved Creative Commons License |
Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-lab
Laboratory results are grouped and summarized using the DiagnosticReport resource which typically reference Observation resource(s). Each Observation resource represents an individual laboratory test and result value or component result values, or a “nested” panel (such as a microbial susceptibility panel) which references other observations. They can also be presented in report form or as free text. This profile sets minimum expectations for the DiagnosticReport resource to record, search, and fetch laboratory results associated with a patient. It identifies which core elements, extensions, vocabularies and value sets SHALL be present in the resource when using this profile.
Example Usage Scenarios:
The following are example usage scenarios for the US Core DiagnosticReport Profile for Laboratory Results Reporting:
The following data-elements must always be present (Mandatory definition]) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.
Each DiagnosticReport must have:
Each DiagnosticReport must support:
Profile specific implementation guidance:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Summary
Mandatory: 7 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 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 + Binding: DiagnosticReportStatus (required) |
Slices for category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
category:LaboratorySlice | S | 1..1 | CodeableConcept | Service category Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
code | S | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
subject | S | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
effective[x] | S | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
issued | S | 1..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core CareTeam Profile | US Core PractitionerRole Profile) | Responsible Diagnostic Service |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 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 | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier for report |
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
issued | SΣ | 1..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core CareTeam Profile | US Core PractitionerRole Profile) | Responsible Diagnostic Service |
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |
media | Σ | 0..* | BackboneElement | Key images associated with this report |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comment | 0..1 | string | Comment about the image (e.g. explanation) | |
link | Σ | 1..1 | Reference(Media) | Reference to the image source |
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |
presentedForm | 0..* | Attachment | Entire report as issued | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
code | Σ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
subject | Σ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
effective[x] | Σ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime | |||
issued | Σ | 1..1 | instant | DateTime this version was made |
performer | Σ | 0..* | Reference(US Core Practitioner Profile) | Responsible Diagnostic Service |
result | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations | |
Documentation for this format |
This structure is derived from DiagnosticReport
Summary
Mandatory: 7 elements
Must-Support: 9 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 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 + Binding: DiagnosticReportStatus (required) |
Slices for category | S | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this |
category:LaboratorySlice | S | 1..1 | CodeableConcept | Service category Required Pattern: At least the following |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
code | S | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
subject | S | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
effective[x] | S | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
issued | S | 1..1 | instant | DateTime this version was made |
performer | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core CareTeam Profile | US Core PractitionerRole Profile) | Responsible Diagnostic Service |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
Documentation for this format |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 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 | Σ | 0..1 | Meta | Metadata about the resource |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages: A human language. | |
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |
contained | 0..* | Resource | Contained, inline Resources | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | Σ | 0..* | Identifier | Business identifier for report |
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required) |
Slices for category | SΣ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by pattern:$this Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
category:LaboratorySlice | SΣ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. Required Pattern: At least the following |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074 | |
version | 0..1 | string | Version of the system - if relevant | |
code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: LAB | |
display | 0..1 | string | Representation defined by the system | |
userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
text | 0..1 | string | Plain text representation of the concept | |
code | SΣ | 1..1 | CodeableConcept | US Core Laboratory Report Order Code Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | The subject of the report - usually, but not always, the patient |
encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Clinically relevant time/time-period for report | |
effectiveDateTime | dateTime S | |||
effectivePeriod | Period | |||
issued | SΣ | 1..1 | instant | DateTime this version was made |
performer | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core CareTeam Profile | US Core PractitionerRole Profile) | Responsible Diagnostic Service |
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter |
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |
result | S | 0..* | Reference(US Core Laboratory Result Observation Profile) | Observations |
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |
media | Σ | 0..* | BackboneElement | Key images associated with this report |
id | 0..1 | string | Unique id for inter-element referencing | |
extension | 0..* | Extension | Additional content defined by implementations | |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
comment | 0..1 | string | Comment about the image (e.g. explanation) | |
link | Σ | 1..1 | Reference(Media) | Reference to the image source |
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |
presentedForm | 0..* | Attachment | Entire report as issued | |
Documentation for this format |
Other representations of profile: CSV, Excel, Schematron
Path | Conformance | ValueSet / Code |
DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
DiagnosticReport.status | required | DiagnosticReportStatus |
DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
DiagnosticReport.category:LaboratorySlice | example | Pattern: LAB |
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodes |
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.
The following search parameters and search parameter combinations SHALL be supported:
SHALL support searching for all diagnosticreports for a patient using the patient
search parameter:
GET [base]/DiagnosticReport?patient={Type/}[id]
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient (how to search by reference)
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/DiagnosticReport?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/v2-0074|LAB
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code = LAB
(how to search by reference and how to search by token)
patient
and code
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/DiagnosticReport?patient={Type/}[id]&category=http://terminology.hl7.org/CodeSystem/v2-0074|LAB&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code = LAB
(how to search by reference and how to search by token and how to search by date)
The following search parameter combinations SHOULD be supported:
patient
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/DiagnosticReport?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and status (how to search by reference and how to search by token)
patient
and code
and date
search parameters:
code
(e.g.code={system|}[code],{system|}[code],...
)date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)