2nd DSTU Draft For Comment

This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Profile: cqf-diagnosticreport

The official URL for this profile is: 

http://hl7.org/fhir/Profile/cqf-diagnosticreport-cqf-diagnosticreport

. Profile of Diagnostic Report for decision support/quality metrics. Indicates which elements must be supported by CQF rules and measure engines. : Clinical Quality Framework (CQF) Diagnostic Report Profile

This profile was published on Tue, Nov 25, 2014 00:00+1100 as a draft by Health Level Seven, Inc. - CQI WG.

Summary

Terminology Bindings

Required/Prohibited Elements

  • The element DiagnosticReport is required
  • The element DiagnosticReport.name is required
  • The element DiagnosticReport.status is required
  • The element DiagnosticReport.issued is required
  • The element DiagnosticReport.subject is required
  • The element DiagnosticReport.performer is required
  • The element DiagnosticReport.diagnostic[x] is required

Formal Views of Profile Content

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

Differential View

This structure is derived from DiagnosticReport.

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..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
... name S1..1CodeableConceptName/Code for this diagnostic report
Binding: DiagnosticReportNames (preferred, extensible)
... status M SΣ1..1codefinal | corrected | amended +
Binding: CQFDiagnosticReportStatus (preferred, extensible)
... issued S Σ1..1dateTimeDate this version was released
... subject S Σ1..1Patient, Group, Device, LocationThe subject of the report, usually, but not always, the patient
... performer S Σ1..1Practitioner, OrganizationResponsible Diagnostic Service
... encounter Σ0..1EncounterHealth care event when test ordered
... identifier Σ0..1IdentifierId for external references to this report
... requestDetail 0..*DiagnosticOrderWhat was requested
... serviceCategory S Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example, extensible)
... diagnostic[x] S Σ1..1dateTime, PeriodPhysiologically Relevant time/time-period for report
... specimen S0..*SpecimenSpecimens this report is based on
... result S0..*ObservationObservations - simple, or complex nested groups
... imagingStudy S0..*ImagingStudyReference to full details of imaging associated with the diagnostic report
... image S Σ0..*Key images associated with this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1MediaReference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: AdjunctDiagnosis (example, extensible)
... presentedForm 0..*AttachmentEntire Report as issued

XML Template

JSON Template

todo

Differential View

This structure is derived from DiagnosticReport.

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id 0..1idLogical id of this artefact
... meta 0..1MetaMetadata about the resource
... implicitRules M0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Language (required, not extensible)
... text I0..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
... name S1..1CodeableConceptName/Code for this diagnostic report
Binding: DiagnosticReportNames (preferred, extensible)
... status M SΣ1..1codefinal | corrected | amended +
Binding: CQFDiagnosticReportStatus (preferred, extensible)
... issued S Σ1..1dateTimeDate this version was released
... subject S Σ1..1Patient, Group, Device, LocationThe subject of the report, usually, but not always, the patient
... performer S Σ1..1Practitioner, OrganizationResponsible Diagnostic Service
... encounter Σ0..1EncounterHealth care event when test ordered
... identifier Σ0..1IdentifierId for external references to this report
... requestDetail 0..*DiagnosticOrderWhat was requested
... serviceCategory S Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example, extensible)
... diagnostic[x] S Σ1..1dateTime, PeriodPhysiologically Relevant time/time-period for report
... specimen S0..*SpecimenSpecimens this report is based on
... result S0..*ObservationObservations - simple, or complex nested groups
... imagingStudy S0..*ImagingStudyReference to full details of imaging associated with the diagnostic report
... image S Σ0..*Key images associated with this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension 0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1MediaReference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: AdjunctDiagnosis (example, extensible)
... presentedForm 0..*AttachmentEntire Report as issued

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
DiagnosticReport.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
DiagnosticReport.nameDiagnosticReportNamespreferred (extensible)LOINC Diagnostic Report Codes
DiagnosticReport.statusCQFDiagnosticReportStatuspreferred (extensible)CQFDiagnosticReportStatus
DiagnosticReport.serviceCategoryDiagnosticServiceSectionexample (extensible)LOINC Diagnostic Report Codes
DiagnosticReport.codedDiagnosisAdjunctDiagnosisexample (extensible)SNOMED CT Clinical Findings

Constraints

IdPathNameDetails
.