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: DAFDiagnosticReport

The official URL for this profile is: 

http://hl7.org/fhir/Profile/diagnosticreport-daf-dafdiagnosticreport

. DAF Diagnostic Report

This profile was published on Wed, Nov 19, 2014 00:00+1100 as a draft by U.S. Office of the National Coordinator (ONC).

Summary

Required/Prohibited Elements

  • The element DiagnosticReport is required
  • The element DiagnosticReport.text is required
  • The element DiagnosticReport.text.status is required
  • The element DiagnosticReport.name is required
  • The element DiagnosticReport.name.coding.system is required
  • The element DiagnosticReport.name.coding.code is required
  • The element DiagnosticReport.name.coding.system is required
  • The element DiagnosticReport.name.coding.code 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.identifier is required
  • The element DiagnosticReport.identifier.use is required
  • The element DiagnosticReport.identifier.label is required
  • The element DiagnosticReport.identifier.system is required
  • The element DiagnosticReport.identifier.value is required
  • The element DiagnosticReport.requestDetail is required
  • The element DiagnosticReport.diagnostic[x] is required
  • The element DiagnosticReport.imagingStudy is prohibited

Fixed Values

  • The element DiagnosticReport.text.status value has been fixed to generated
  • The element DiagnosticReport.name.coding.system value has been fixed to http://loinc.org
  • The element DiagnosticReport.identifier.use value has been fixed to official
  • The element DiagnosticReport.identifier.label value has been fixed to Laboratory Report ID

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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DAF Diagnostic Report
... text S1..1
.... status S1..1codeFixed Value: generated
... name S I1..1US Realm Laboratory Report Order Code
inv-2: Must have a LOINC or a Local code or both.
.... coding Slice: Unordered, Open, by system
.... coding S I0..1LOINC coding if concept exists in LOINC
..... system S1..1uriLOINC Coding System
Fixed Value: http://loinc.org
..... code S1..1LOINC
..... display S0..1LOINC Display Name
.... coding S I0..1
..... system S1..1uriLocal Coding System
..... code S1..1Local Code
..... display S0..1Local Code Display name
.... text S0..1Display text
... status S1..1
... issued S I1..1inv-1: Datetime must be at least to second.
... subject S1..1patient-daf-dafpatient
... performer S1..1
... identifier S1..1
.... use S1..1codeFixed Value: official
.... label S1..1stringFixed Value: Laboratory Report ID
.... system S1..1Lab URI
.... value S1..1
... requestDetail S1..*diagnosticorder-daf-dafdiagnosticorder
... diagnostic[x] S1..1dateTime, PeriodSpecimen Collection Datetime or Period
... result S0..*observation-daf-results-dafresultobservationcode, observation-daf-results-dafresultobsquantity, observation-daf-results-dafresultobsratio, observation-daf-results-dafresultobsother
... imagingStudy 0..0
... conclusion S0..1
... codedDiagnosis S0..*
... presentedForm S0..*

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DAF Diagnostic Report
... 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 S I1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... status S1..1codegenerated | extensions | additional
Binding: NarrativeStatus (required, not extensible)
Fixed Value: generated
.... div I1..1xhtmlLimited xhtml content
txt-2: The narrative SHALL have some non-whitespace content
txt-1: The narrative SHALL contain only the basic html formatting elements described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
txt-3: The narrative SHALL contain only the basic html formatting attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... name S I1..1CodeableConceptUS Realm Laboratory Report Order Code
Binding: DiagnosticReportNames (preferred, extensible)
inv-2: Must have a LOINC or a Local code or both.
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding CodingCode defined by a terminology system
Slice: Unordered, Open, by system
.... coding S0..1CodingLOINC coding if concept exists in LOINC
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriLOINC Coding System
Fixed Value: http://loinc.org
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeLOINC
..... display S0..1stringLOINC Display Name
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... coding S0..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriLocal Coding System
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeLocal Code
..... display S0..1stringLocal Code Display name
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text S0..1stringDisplay text
... status M SΣ1..1coderegistered | partial | final | corrected +
Binding: DiagnosticReportStatus (required, not extensible)
... issued S ΣI1..1dateTimeDate this version was released
inv-1: Datetime must be at least to second.
... subject S Σ1..1patient-daf-dafpatientThe 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 S Σ1..1IdentifierId for external references to this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... use M S1..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required, not extensible)
Fixed Value: official
.... label S1..1stringDescription of identifier
Fixed Value: Laboratory Report ID
.... system S1..1uriLab URI
Example: http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri
.... value S1..1stringThe value that is unique
Example: 123456
.... period 0..1PeriodTime period when id is/was valid for use
.... assigner 0..1OrganizationOrganization that issued id (may be just text)
... requestDetail S1..*diagnosticorder-daf-dafdiagnosticorderWhat was requested
... serviceCategory Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example, extensible)
... diagnostic[x] S Σ1..1dateTime, PeriodSpecimen Collection Datetime or Period
... specimen 0..*SpecimenSpecimens this report is based on
... result S0..*observation-daf-results-dafresultobservationcode, observation-daf-results-dafresultobsquantity, observation-daf-results-dafresultobsratio, observation-daf-results-dafresultobsotherObservations - simple, or complex nested groups
... image 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 S0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: AdjunctDiagnosis (example, extensible)
... presentedForm S0..*AttachmentEntire Report as issued

XML Template

JSON Template

todo

Differential View

This structure is derived from DiagnosticReport.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DAF Diagnostic Report
... text S1..1
.... status S1..1codeFixed Value: generated
... name S I1..1US Realm Laboratory Report Order Code
inv-2: Must have a LOINC or a Local code or both.
.... coding Slice: Unordered, Open, by system
.... coding S I0..1LOINC coding if concept exists in LOINC
..... system S1..1uriLOINC Coding System
Fixed Value: http://loinc.org
..... code S1..1LOINC
..... display S0..1LOINC Display Name
.... coding S I0..1
..... system S1..1uriLocal Coding System
..... code S1..1Local Code
..... display S0..1Local Code Display name
.... text S0..1Display text
... status S1..1
... issued S I1..1inv-1: Datetime must be at least to second.
... subject S1..1patient-daf-dafpatient
... performer S1..1
... identifier S1..1
.... use S1..1codeFixed Value: official
.... label S1..1stringFixed Value: Laboratory Report ID
.... system S1..1Lab URI
.... value S1..1
... requestDetail S1..*diagnosticorder-daf-dafdiagnosticorder
... diagnostic[x] S1..1dateTime, PeriodSpecimen Collection Datetime or Period
... result S0..*observation-daf-results-dafresultobservationcode, observation-daf-results-dafresultobsquantity, observation-daf-results-dafresultobsratio, observation-daf-results-dafresultobsother
... imagingStudy 0..0
... conclusion S0..1
... codedDiagnosis S0..*
... presentedForm S0..*

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 1..1DAF Diagnostic Report
... 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 S I1..1NarrativeText summary of the resource, for human interpretation
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... status S1..1codegenerated | extensions | additional
Binding: NarrativeStatus (required, not extensible)
Fixed Value: generated
.... div I1..1xhtmlLimited xhtml content
txt-2: The narrative SHALL have some non-whitespace content
txt-1: The narrative SHALL contain only the basic html formatting elements described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
txt-3: The narrative SHALL contain only the basic html formatting attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension 0..*ExtensionExtensions that cannot be ignored
... name S I1..1CodeableConceptUS Realm Laboratory Report Order Code
Binding: DiagnosticReportNames (preferred, extensible)
inv-2: Must have a LOINC or a Local code or both.
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... coding CodingCode defined by a terminology system
Slice: Unordered, Open, by system
.... coding S0..1CodingLOINC coding if concept exists in LOINC
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriLOINC Coding System
Fixed Value: http://loinc.org
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeLOINC
..... display S0..1stringLOINC Display Name
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... coding S0..1CodingCode defined by a terminology system
..... id 0..1idxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... system S1..1uriLocal Coding System
..... version 0..1stringVersion of the system - if relevant
..... code S1..1codeLocal Code
..... display S0..1stringLocal Code Display name
..... primary 0..1booleanIf this code was chosen directly by the user
..... valueSet 0..1ValueSetSet this coding was chosen from
.... text S0..1stringDisplay text
... status M SΣ1..1coderegistered | partial | final | corrected +
Binding: DiagnosticReportStatus (required, not extensible)
... issued S ΣI1..1dateTimeDate this version was released
inv-1: Datetime must be at least to second.
... subject S Σ1..1patient-daf-dafpatientThe 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 S Σ1..1IdentifierId for external references to this report
.... id 0..1idxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... use M S1..1codeusual | official | temp | secondary (If known)
Binding: IdentifierUse (required, not extensible)
Fixed Value: official
.... label S1..1stringDescription of identifier
Fixed Value: Laboratory Report ID
.... system S1..1uriLab URI
Example: http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri
.... value S1..1stringThe value that is unique
Example: 123456
.... period 0..1PeriodTime period when id is/was valid for use
.... assigner 0..1OrganizationOrganization that issued id (may be just text)
... requestDetail S1..*diagnosticorder-daf-dafdiagnosticorderWhat was requested
... serviceCategory Σ0..1CodeableConceptBiochemistry, Hematology etc.
Binding: DiagnosticServiceSection (example, extensible)
... diagnostic[x] S Σ1..1dateTime, PeriodSpecimen Collection Datetime or Period
... specimen 0..*SpecimenSpecimens this report is based on
... result S0..*observation-daf-results-dafresultobservationcode, observation-daf-results-dafresultobsquantity, observation-daf-results-dafresultobsratio, observation-daf-results-dafresultobsotherObservations - simple, or complex nested groups
... image 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 S0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: AdjunctDiagnosis (example, extensible)
... presentedForm S0..*AttachmentEntire Report as issued

XML Template

JSON Template

todo

 

Other definitions: (todo)

Terminology Bindings

PathNameConformanceValueSet
DiagnosticReport.languageLanguagerequiredhttp://tools.ietf.org/html/bcp47
DiagnosticReport.text.statusNarrativeStatusrequiredNarrativeStatus
DiagnosticReport.nameDiagnosticReportNamespreferred (extensible)LOINC Diagnostic Report Codes
DiagnosticReport.statusDiagnosticReportStatusrequiredDiagnosticReportStatus
DiagnosticReport.identifier.useIdentifierUserequiredIdentifierUse
DiagnosticReport.serviceCategoryDiagnosticServiceSectionexample (extensible)LOINC Diagnostic Report Codes
DiagnosticReport.codedDiagnosisAdjunctDiagnosisexample (extensible)SNOMED CT Clinical Findings

Constraints

IdPathNameDetails
txt-2DiagnosticReport.text.divThe narrative SHALL have some non-whitespace content
XPath: descendant::text()[normalize-space(.)!=''] or descendant::h:img[@src]
txt-1DiagnosticReport.text.divThe narrative SHALL contain only the basic html formatting elements described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
XPath: not(descendant-or-self::*[not(local-name(.)=('a', 'abbr', 'acronym', 'b', 'big', 'blockquote', 'br', 'caption', 'cite', 'code', 'colgroup', 'dd', 'dfn', 'div', 'dl', 'dt', 'em', 'h1', 'h2', 'h3', 'h4', 'h5', 'h6', 'hr', 'i', 'img', 'li', 'ol', 'p', 'pre', 'q', 'samp', 'small', 'span', 'strong', 'table', 'tbody', 'td', 'tfoot', 'th', 'thead', 'tr', 'tt', 'ul', 'var'))])
txt-3DiagnosticReport.text.divThe narrative SHALL contain only the basic html formatting attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes
XPath: not(descendant-or-self::*/@*[not(name(.)=('abbr', 'accesskey', 'align', 'alt', 'axis', 'bgcolor', 'border', 'cellhalign', 'cellpadding', 'cellspacing', 'cellvalign', 'char', 'charoff', 'charset', 'cite', 'class', 'colspan', 'compact', 'coords', 'dir', 'frame', 'headers', 'height', 'href', 'hreflang', 'hspace', 'id', 'lang', 'longdesc', 'name', 'nowrap', 'rel', 'rev', 'rowspan', 'rules', 'scope', 'shape', 'span', 'src', 'start', 'style', 'summary', 'tabindex', 'title', 'type', 'valign', 'value', 'vspace', 'width'))])
inv-2DiagnosticReport.nameLOINC or LocalMust have a LOINC or a Local code or both.
XPath: exists(f:coding)
inv-1DiagnosticReport.issueddatetime to secondDatetime must be at least to second.
XPath: f:matches(issued,/\d{4}-[01]\d-[0-3]\dT[0-2]\d:[0-5]\d([+-][0-2]\d:[0-5]\d|Z)/)
.