QI-Core Implementation Guide: STU Ballot (v3.3.0 for FHIR 4.0.0)

Quality Improvement Core Framework (v3.3.0: STU 4 Ballot 1). The current version is 3.2.0 based on FHIR R4. See the Directory of published versions

D.4.1 StructureDefinition-qicore-diagnosticreport-note

Introduction:

See the patterns page for implementation and usage patterns.

Examples:

TODO

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is: 

http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note

Profile of DiagnosticReport for Note exchange for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

This profile builds on USCoreDiagnosticReportProfileNoteExchange.

This profile was published on Wed Aug 22 00:00:00 EDT 2018 as a draft by Health Level Seven, Inc. - CQI WG.

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*US Core Diagnostic Report Profile for Report and Note exchange
... 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: CommonLanguages (preferred)
Max Binding: AllLanguages
... 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-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... locationPerformed-valueReference 1..1Reference(QICoreLocation)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..*CodeableConceptService category
Binding: US Core DiagnosticReport Category (extensible)
... code Σ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
... subject Σ1..1Reference(QICorePatient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(QICoreEncounter)Health care event when test ordered
... effective[x] Σ1..1Time of the report or note
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(QICoreSpecimen)Specimens this report is based on
... result S0..*Reference(QICoreObservation)Observations
... imagingStudy S0..*Reference(QICoreImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*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 S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (preferred)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*US Core Diagnostic Report Profile for Report and Note exchange
... 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: CommonLanguages (preferred)
Max Binding: AllLanguages
... 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-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... locationPerformed-valueReference 1..1Reference(QICoreLocation)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..*CodeableConceptService category
Binding: US Core DiagnosticReport Category (extensible)
... code Σ1..1CodeableConceptUS Core Report Code
Binding: US Core Diagnosticreport Report And Note Codes (extensible)
... subject Σ1..1Reference(QICorePatient)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(QICoreEncounter)Health care event when test ordered
... effective[x] Σ1..1Time of the report or note
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(QICorePractitioner | QICorePractitionerRole | QICoreOrganization)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(QICoreSpecimen)Specimens this report is based on
... result S0..*Reference(QICoreObservation)Observations
... imagingStudy S0..*Reference(QICoreImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣI0..*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 S0..1stringClinical conclusion (interpretation) of test results
... conclusionCode S0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (preferred)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryextensibleUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreDiagnosticreportReportAndNoteCodes
DiagnosticReport.conclusionCodepreferredSNOMEDCTClinicalFindings

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-4DiagnosticReportIf 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-3DiagnosticReportIf 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-6DiagnosticReportA resource should have narrative for robust management
: text.div.exists()
dom-5DiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())