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 for USLab Specimen Resource
{ "resourceType": "Profile", "id": "spec-uslab-uslabspec", "text": { "status": "generated", "div": "<div>!-- Snipped for Brevity --></div>" }, "url": "http://hl7.org/fhir/Profile/spec-uslab-uslabspec", "name": "US Laboratory Specimen Profile", "publisher": "HL7 International - Orders and Observations WG", "contact": [ { "telecom": [ { "system": "url", "value": "http://hl7.org" } ] } ], "description": "USLab Specimen Resource", "status": "draft", "date": "2014-11-17", "type": "Specimen", "base": "http://hl7.org/fhir/Profile/Specimen", "snapshot": { "element": [ { "path": "Specimen", "name": "USLabSpec", "short": "USLab Specimen Resource", "definition": "Specimen resource defined for the USLab Implementation Guides.", "synonym": [ "Sample" ], "min": 1, "max": "1", "mapping": [ { "identity": "rim", "map": "Role[classCode=SPEC]" } ] }, { "path": "Specimen.id", "short": "Logical id of this artefact", "definition": "The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.", "comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.", "min": 0, "max": "1", "type": [ { "code": "id" } ] }, { "path": "Specimen.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.", "min": 0, "max": "1", "type": [ { "code": "Meta" } ] }, { "path": "Specimen.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.", "comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.", "min": 0, "max": "1", "type": [ { "code": "uri" } ], "isModifier": true }, { "path": "Specimen.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource\n\nNot all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "type": [ { "code": "code" } ], "binding": { "name": "Language", "isExtensible": false, "conformance": "required", "description": "A human language", "referenceUri": "http://tools.ietf.org/html/bcp47" } }, { "path": "Specimen.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.", "synonym": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "type": [ { "code": "Narrative" } ], "condition": [ "dom-1" ], "mapping": [ { "identity": "rim", "map": "Act.text?" } ] }, { "path": "Specimen.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.", "synonym": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.identifier", "slicing": { "discriminator": [ "identifier.label" ], "ordered": true, "rules": "openAtEnd" }, "short": "External Identifier", "definition": "Id for specimen.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "v2", "map": "SPM-2" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Specimen.identifier", "name": "USLabPlacerSID", "short": "External Identifier", "definition": "Id for specimen.", "min": 0, "max": "1", "type": [ { "code": "Identifier" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "SPM-2" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Specimen.identifier.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.identifier.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.identifier.use", "short": "usual | official | temp | secondary (If known)", "definition": "The purpose of this identifier.", "comments": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "fixedCode": "official", "mustSupport": true, "isModifier": true, "binding": { "name": "IdentifierUse", "isExtensible": false, "conformance": "required", "description": "Identifies the purpose for this identifier, if known", "referenceReference": { "reference": "http://hl7.org/fhir/vs/identifier-use" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "path": "Specimen.identifier.label", "short": "Description of identifier", "definition": "A text string for the identifier that can be displayed to a human so they can recognize the identifier.", "requirements": "Allows humans to make use of identifiers when the identifier system is not known.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "fixedString": "Placer Specimen ID", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.title or implied by context" } ] }, { "path": "Specimen.identifier.system", "short": "Placer URI", "definition": "Placer URI.", "requirements": "There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "exampleUri": "http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "path": "Specimen.identifier.value", "short": "Placer Identifier", "definition": "Placer Identifier.", "comments": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "exampleString": "123456", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "path": "Specimen.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "path": "Specimen.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comments": "The reference may be just a text description of the assigner.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Organization" } ], "mapping": [ { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "path": "Specimen.type", "short": "Kind of material that forms the specimen", "definition": "The kind of material that forms the specimen.", "comments": "The type can change the way that a specimen is handled, and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems.", "min": 1, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "name": "SpecimenType", "isExtensible": true, "conformance": "example", "description": "The type of the specimen.", "referenceReference": { "reference": "http://hl7.org/fhir/v2/vs/0487" } }, "mapping": [ { "identity": "v2", "map": "SPM-4 and possibly SPM-5" }, { "identity": "rim", "map": ".code" } ] }, { "path": "Specimen.type.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.coding", "slicing": { "discriminator": [ "system" ], "ordered": false, "rules": "open" }, "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 0, "max": "*", "type": [ { "code": "Coding" } ], "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.type.coding", "name": "USLabSNOMEDCTCoding", "short": "SNOMED-CT coding if available", "definition": "SNOMED-CT coding if available.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "synonym": [ "Snomed Code" ], "min": 0, "max": "1", "type": [ { "code": "Coding" } ], "mustSupport": true, "binding": { "name": "USLabSpecimenType", "isExtensible": true, "conformance": "required", "description": "Codes to describe the Specimen", "referenceReference": { "reference": "http://hl7.org/fhir/vs/spec-uslab-type" } }, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.type.coding.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.coding.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.coding.system", "short": "SNOMED-CT Coding System", "definition": "SNOMED-CT Coding System.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "fixedUri": "http://snomed.info/sct", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" } ] }, { "path": "Specimen.type.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" } ] }, { "path": "Specimen.type.coding.code", "short": "SNOMED-CT", "definition": "SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" } ] }, { "path": "Specimen.type.coding.display", "short": "SNOMED-CT Display Name", "definition": "The SNOMED-CT 'preferred name' is preferred although any SNOMED-CT 'synonym' can also be used. ( ihtsdo.org/snomed-ct/).", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" } ] }, { "path": "Specimen.type.coding.primary", "short": "If this code was chosen directly by the user", "definition": "Indicates that this code was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations.", "requirements": "This has been identified as a clinical safety criterium - that this exact code was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" } ] }, { "path": "Specimen.type.coding.valueSet", "short": "Set this coding was chosen from", "definition": "The set of possible coded values this coding was chosen from or constrained by.", "requirements": "The value set may influence the codes that the user can select. Also, referencing the value set directly makes it easier to share ad-hoc code systems used across healthcare.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/ValueSet" } ], "mapping": [ { "identity": "v2", "map": "C*E.16 - .19" }, { "identity": "rim", "map": "CD.valueSet / CD.valueSetVersion" } ] }, { "path": "Specimen.type.coding", "name": "USLabLocalCoding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "synonym": [ "Local" ], "min": 0, "max": "1", "type": [ { "code": "Coding" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.type.coding.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.coding.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.type.coding.system", "short": "Local Coding System", "definition": "This is defined locally.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" } ] }, { "path": "Specimen.type.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" } ] }, { "path": "Specimen.type.coding.code", "short": "Local Code", "definition": "Local Code.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" } ] }, { "path": "Specimen.type.coding.display", "short": "local Code Display name", "definition": "This is defined locally.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" } ] }, { "path": "Specimen.type.coding.primary", "short": "If this code was chosen directly by the user", "definition": "Indicates that this code was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations.", "requirements": "This has been identified as a clinical safety criterium - that this exact code was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" } ] }, { "path": "Specimen.type.coding.valueSet", "short": "Set this coding was chosen from", "definition": "The set of possible coded values this coding was chosen from or constrained by.", "requirements": "The value set may influence the codes that the user can select. Also, referencing the value set directly makes it easier to share ad-hoc code systems used across healthcare.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/ValueSet" } ], "mapping": [ { "identity": "v2", "map": "C*E.16 - .19" }, { "identity": "rim", "map": "CD.valueSet / CD.valueSetVersion" } ] }, { "path": "Specimen.type.text", "short": "Display text", "definition": "This is the laboratory defined display text for the actual test result, if different from the code display names.", "comments": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" } ] }, { "path": "Specimen.parent", "short": "Parent specimen", "definition": "Reference to the parent (source) specimen which is used when the specimen was either derived from or a component of a another specimen.", "comments": "The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Specimen" } ], "mapping": [ { "identity": "rim", "map": ".scoper (if parent)\n.player.scopesRole[classCode=SPEC].player (if child)" } ] }, { "path": "Specimen.subject", "short": "Patient", "definition": "Patient.", "requirements": "Must know the subject context.", "synonym": [ "Patient" ], "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/patient-uslab-uslabpatient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/patient-uslab-uslabphpatient" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": ".scoper\n\nor\n\n.scoper.playsRole" } ] }, { "path": "Specimen.accessionIdentifier", "short": "Identifier assigned by the lab", "definition": "The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.", "synonym": [ "Filler ID" ], "min": 1, "max": "1", "type": [ { "code": "Identifier" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "SPM-30 (v2.7+)" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].act[classCode=ACSN, moodCode=EVN].id" } ] }, { "path": "Specimen.accessionIdentifier.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.accessionIdentifier.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.accessionIdentifier.use", "short": "usual | official | temp | secondary (If known)", "definition": "The purpose of this identifier.", "comments": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "fixedCode": "official", "mustSupport": true, "isModifier": true, "binding": { "name": "IdentifierUse", "isExtensible": false, "conformance": "required", "description": "Identifies the purpose for this identifier, if known", "referenceReference": { "reference": "http://hl7.org/fhir/vs/identifier-use" } }, "mapping": [ { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "path": "Specimen.accessionIdentifier.label", "short": "Description of identifier", "definition": "A text string for the identifier that can be displayed to a human so they can recognize the identifier.", "requirements": "Allows humans to make use of identifiers when the identifier system is not known.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.title or implied by context" } ] }, { "path": "Specimen.accessionIdentifier.system", "short": "Filler URI", "definition": "Filler URI.", "requirements": "There are many sequences of identifiers. To perform matching, we need to know what sequence we're dealing with. The system identifies a particular sequence or set of unique identifiers.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "exampleUri": "http://www.acme.com/identifiers/patient or urn:ietf:rfc:3986 if the id itself is a full uri", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "path": "Specimen.accessionIdentifier.value", "short": "Filler Identifier", "definition": "Filler Identifier.", "comments": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986.", "min": 1, "max": "1", "type": [ { "code": "string" } ], "exampleString": "123456", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "path": "Specimen.accessionIdentifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "min": 0, "max": "1", "type": [ { "code": "Period" } ], "mapping": [ { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "path": "Specimen.accessionIdentifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comments": "The reference may be just a text description of the assigner.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Organization" } ], "mapping": [ { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "path": "Specimen.receivedTime", "short": "The time when specimen was received for processing", "definition": "Time when specimen was received for processing or testing.", "min": 0, "max": "1", "type": [ { "code": "dateTime" } ], "mapping": [ { "identity": "v2", "map": "SPM-18" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].act[code=SPCREC, moodCode=EVN].effectiveTime" } ] }, { "path": "Specimen.collection", "short": "Collection details", "definition": "Details concerning the specimen collection.", "min": 1, "max": "1", "mustSupport": true, "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SBJ].act[classCode=SPECCOLLECT, moodCode=EVN]" } ] }, { "path": "Specimen.collection.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.collection.collector", "short": "Who collected the specimen", "definition": "Person who collected the specimen.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Practitioner" } ], "mapping": [ { "identity": "rim", "map": ".participation[typeCode=PFM].role" } ] }, { "path": "Specimen.collection.comment", "short": "Collector comments", "definition": "To communicate any details or issues encountered during the specimen collection procedure.", "min": 0, "max": "*", "type": [ { "code": "string" } ], "mapping": [ { "identity": "rim", "map": ".inboundRelationship[typeCode=SUBJ].source[classCode=OBS, moodCode=EVN, code=\"annotation\"].value" } ] }, { "path": "Specimen.collection.collected[x]", "short": "Collection time", "definition": "Time when specimen was collected from subject - the physiologically relevant time.", "min": 1, "max": "1", "type": [ { "code": "dateTime" }, { "code": "Period" } ], "constraint": [ { "key": "inv-2", "name": "datetime to day", "severity": "error", "human": "Datetime must be at least to the day.", "xpath": "f:matches(.,/\\d{4}-[01]\\d-[0-3])/)" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "SPM-17" }, { "identity": "rim", "map": ".effectiveTime" } ] }, { "path": "Specimen.collection.quantity", "short": "The quantity of specimen collected", "definition": "The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample.", "min": 0, "max": "1", "type": [ { "code": "Quantity" } ], "mapping": [ { "identity": "v2", "map": "SPM-12" }, { "identity": "rim", "map": ".participation[typeCode=SBJ].role[classCode=SPEC].player.quantity" } ] }, { "path": "Specimen.collection.method", "short": "Technique used to perform collection", "definition": "A coded value specifying the technique that is used to perform the procedure.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "SpecimenCollectionMethod", "isExtensible": true, "conformance": "example", "description": "The technique that is used to perform the procedure", "referenceReference": { "reference": "http://hl7.org/fhir/vs/specimen-collection-method" } }, "mapping": [ { "identity": "v2", "map": "SPM-7" }, { "identity": "rim", "map": ".methodCode" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept", "short": "Anatomical collection site", "definition": "Anatomical location from which the specimen was collected (if subject is a patient). This element is not used for environmental specimens.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true, "binding": { "name": "BodySite", "isExtensible": true, "conformance": "example", "description": "Codes describing anatomical locations. May include laterality", "referenceReference": { "reference": "http://hl7.org/fhir/vs/body-site" } }, "mapping": [ { "identity": "v2", "map": "SPM-8 and SPM-9" }, { "identity": "rim", "map": ".approachSiteCode" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding", "slicing": { "discriminator": [ "system" ], "ordered": false, "rules": "open" }, "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "min": 0, "max": "*", "type": [ { "code": "Coding" } ], "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding", "name": "USLabSNOMEDCTCoding", "short": "SNOMED-CT coding if available", "definition": "SNOMED-CT coding if available.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "synonym": [ "Snomed Code" ], "min": 0, "max": "1", "type": [ { "code": "Coding" } ], "mustSupport": true, "binding": { "name": "USLabSpecimenbodySite[x]", "isExtensible": true, "conformance": "required", "description": "Codes to describe the Specimen Collection Body site", "referenceReference": { "reference": "http://hl7.org/fhir/vs/body-site" } }, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.system", "short": "SNOMED-CT Coding System", "definition": "SNOMED-CT Coding System.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "fixedUri": "http://snomed.info/sct", "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.code", "short": "SNOMED-CT", "definition": "SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.display", "short": "SNOMED-CT Display Name", "definition": "The SNOMED-CT 'preferred name' is preferred although any SNOMED-CT 'synonym' can also be used. ( ihtsdo.org/snomed-ct/).", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.primary", "short": "If this code was chosen directly by the user", "definition": "Indicates that this code was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations.", "requirements": "This has been identified as a clinical safety criterium - that this exact code was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.valueSet", "short": "Set this coding was chosen from", "definition": "The set of possible coded values this coding was chosen from or constrained by.", "requirements": "The value set may influence the codes that the user can select. Also, referencing the value set directly makes it easier to share ad-hoc code systems used across healthcare.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/ValueSet" } ], "mapping": [ { "identity": "v2", "map": "C*E.16 - .19" }, { "identity": "rim", "map": "CD.valueSet / CD.valueSetVersion" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding", "name": "USLabLocalCoding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comments": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the V3 Core Principles for more information. Ordering of codings is undefined and SHALL not be used to infer meaning.", "requirements": "Allows for translations and alternate encodings within a code system. Also supports communication of the same instance to systems requiring different encodings.", "synonym": [ "Local" ], "min": 0, "max": "1", "type": [ { "code": "Coding" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.system", "short": "Local Coding System", "definition": "This is defined locally.", "comments": "The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should de-reference to some definition that establish the system clearly and unambiguously.", "requirements": "Need to be unambiguous about the source of the definition of the symbol.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.3" }, { "identity": "rim", "map": "./codeSystem" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.version", "short": "Version of the system - if relevant", "definition": "The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured. and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.", "comments": "Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "v2", "map": "C*E.7" }, { "identity": "rim", "map": "./codeSystemVersion" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.code", "short": "Local Code", "definition": "Local Code.", "requirements": "Need to refer to a particular code in the system.", "min": 1, "max": "1", "type": [ { "code": "code" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.1" }, { "identity": "rim", "map": "./code" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.display", "short": "local Code Display name", "definition": "This is defined locally.", "requirements": "Need to be able to carry a human-readable meaning of the code for readers that do not know the system.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.2 - but note this is not well followed" }, { "identity": "rim", "map": "CV.displayName" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.primary", "short": "If this code was chosen directly by the user", "definition": "Indicates that this code was chosen by a user directly - i.e. off a pick list of available items (codes or displays).", "comments": "Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations.", "requirements": "This has been identified as a clinical safety criterium - that this exact code was chosen explicitly, rather than inferred by the system based on some rules or language processing.", "min": 0, "max": "1", "type": [ { "code": "boolean" } ], "mapping": [ { "identity": "v2", "map": "Sometimes implied by being first" }, { "identity": "rim", "map": "CD.codingRationale" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding.valueSet", "short": "Set this coding was chosen from", "definition": "The set of possible coded values this coding was chosen from or constrained by.", "requirements": "The value set may influence the codes that the user can select. Also, referencing the value set directly makes it easier to share ad-hoc code systems used across healthcare.", "min": 0, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/ValueSet" } ], "mapping": [ { "identity": "v2", "map": "C*E.16 - .19" }, { "identity": "rim", "map": "CD.valueSet / CD.valueSetVersion" } ] }, { "path": "Specimen.collection.bodySiteCodeableConcept.text", "short": "Display text", "definition": "This is the laboratory defined display text for the actual test result, if different from the code display names.", "comments": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mustSupport": true, "mapping": [ { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" } ] }, { "path": "Specimen.treatment", "short": "Treatment and processing step details", "definition": "Details concerning treatment and processing steps for the specimen.", "min": 0, "max": "*", "mapping": [ { "identity": "rim", "map": ".participation[typeCode=SBJ].act[code=SPCTRT, moodCode=EVN]" } ] }, { "path": "Specimen.treatment.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.treatment.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.treatment.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.treatment.description", "short": "Textual description of procedure", "definition": "Textual description of procedure.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "rim", "map": ".text" } ] }, { "path": "Specimen.treatment.procedure", "short": "Indicates the treatment or processing step applied to the specimen", "definition": "A coded value specifying the procedure used to process the specimen.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "SpecimenTreatmentProcedure", "isExtensible": true, "conformance": "example", "description": "Type indicating the technique used to process the specimen", "referenceReference": { "reference": "http://hl7.org/fhir/vs/specimen-treatment-procedure" } }, "mapping": [ { "identity": "rim", "map": ".code" } ] }, { "path": "Specimen.treatment.additive", "short": "Material used in the processing step", "definition": "Material used in the processing step.", "min": 0, "max": "*", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Substance" } ], "mapping": [ { "identity": "v2", "map": "SPM-6" }, { "identity": "rim", "map": ".participation[typeCode=CSM].role[classCode=ADTV].code" } ] }, { "path": "Specimen.container", "short": "Direct container of specimen (tube/slide, etc)", "definition": "The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.", "min": 0, "max": "*", "mapping": [ { "identity": "rim", "map": ".player.scopingRole[classCode=CONT].scoper" } ] }, { "path": "Specimen.container.id", "representation": [ "xmlAttr" ], "short": "xml:id (or equivalent in JSON)", "definition": "unique id for the element within a resource (for internal references).", "min": 0, "max": "1", "type": [ { "code": "id" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.container.extension", "short": "Additional Content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "path": "Specimen.container.modifierExtension", "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.", "comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "synonym": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "type": [ { "code": "Extension" } ], "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "path": "Specimen.container.identifier", "short": "Id for the container", "definition": "Id for container. There may be multiple; a manufacturer's bar code, lab assigned identifier, etc. The container ID may differ from the specimen id in some circumstances.", "min": 0, "max": "*", "type": [ { "code": "Identifier" } ], "mapping": [ { "identity": "v2", "map": "SAC-3" }, { "identity": "rim", "map": ".id" } ] }, { "path": "Specimen.container.description", "short": "Textual description of the container", "definition": "Textual description of the container.", "min": 0, "max": "1", "type": [ { "code": "string" } ], "mapping": [ { "identity": "rim", "map": ".desc" } ] }, { "path": "Specimen.container.type", "short": "Kind of container directly associated with specimen", "definition": "The type of container associated with the specimen (e.g. slide, aliquot, etc).", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "binding": { "name": "SpecimenContainerType", "isExtensible": true, "conformance": "example", "description": "Type of specimen container", "referenceReference": { "reference": "http://hl7.org/fhir/vs/specimen-container-type" } }, "mapping": [ { "identity": "v2", "map": "SPM-27" }, { "identity": "rim", "map": ".code" } ] }, { "path": "Specimen.container.capacity", "short": "Container volume or size", "definition": "The capacity (volume or other measure) the container may contain.", "min": 0, "max": "1", "type": [ { "code": "Quantity" } ], "mapping": [ { "identity": "v2", "map": "one of: SAC 16, SAC17 and SAC 20, or SAC 21 and SAC 20" }, { "identity": "rim", "map": ".quantity" } ] }, { "path": "Specimen.container.specimenQuantity", "short": "Quantity of specimen within container", "definition": "The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type.", "min": 0, "max": "1", "type": [ { "code": "Quantity" } ], "mapping": [ { "identity": "v2", "map": "SAC-23 (value) SAC-24 (units" }, { "identity": "rim", "map": ".playedRole[classCode=CONT].quantity" } ] }, { "path": "Specimen.container.additive[x]", "short": "Additive associated with container", "definition": "Introduced substance to preserve, maintain or enhance the specimen. examples: Formalin, Citrate, EDTA.", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" }, { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/Substance" } ], "binding": { "name": "SpecimenContainerAdditive", "isExtensible": true, "conformance": "example", "description": "Substance added to specimen container", "referenceReference": { "reference": "http://hl7.org/fhir/v2/vs/0371" } }, "mapping": [ { "identity": "v2", "map": "SAC-27" }, { "identity": "rim", "map": ".scopesRole[classCode=ADTV].player" } ] } ] }, "differential": { "element": [ { "path": "Specimen", "name": "USLabSpec", "short": "USLab Specimen Resource", "definition": "Specimen resource defined for the USLab Implementation Guides.", "synonym": [ "Sample" ], "min": 1, "max": "1" }, { "path": "Specimen.identifier", "slicing": { "discriminator": [ "identifier.label" ], "ordered": true, "rules": "openAtEnd" } }, { "path": "Specimen.identifier", "name": "USLabPlacerSID", "min": 0, "max": "1", "mustSupport": true }, { "path": "Specimen.identifier.use", "min": 1, "max": "1", "type": [ { "code": "code" } ], "fixedCode": "official", "mustSupport": true }, { "path": "Specimen.identifier.label", "min": 1, "max": "1", "type": [ { "code": "string" } ], "fixedString": "Placer Specimen ID", "mustSupport": true }, { "path": "Specimen.identifier.system", "short": "Placer URI", "definition": "Placer URI.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.identifier.value", "short": "Placer Identifier", "definition": "Placer Identifier.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.type", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.type.coding", "slicing": { "discriminator": [ "system" ], "ordered": false, "rules": "open" } }, { "path": "Specimen.type.coding", "name": "USLabSNOMEDCTCoding", "short": "SNOMED-CT coding if available", "definition": "SNOMED-CT coding if available.", "synonym": [ "Snomed Code" ], "min": 0, "max": "1", "mustSupport": true, "binding": { "name": "USLabSpecimenType", "isExtensible": true, "conformance": "required", "description": "Codes to describe the Specimen", "referenceReference": { "reference": "http://hl7.org/fhir/vs/spec-uslab-type" } } }, { "path": "Specimen.type.coding.system", "short": "SNOMED-CT Coding System", "definition": "SNOMED-CT Coding System.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "fixedUri": "http://snomed.info/sct", "mustSupport": true }, { "path": "Specimen.type.coding.code", "short": "SNOMED-CT", "definition": "SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.type.coding.display", "short": "SNOMED-CT Display Name", "definition": "The SNOMED-CT 'preferred name' is preferred although any SNOMED-CT 'synonym' can also be used. ( ihtsdo.org/snomed-ct/).", "min": 0, "max": "1", "mustSupport": true }, { "path": "Specimen.type.coding", "name": "USLabLocalCoding", "synonym": [ "Local" ], "min": 0, "max": "1", "mustSupport": true }, { "path": "Specimen.type.coding.system", "short": "Local Coding System", "definition": "This is defined locally.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true }, { "path": "Specimen.type.coding.code", "short": "Local Code", "definition": "Local Code.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.type.coding.display", "short": "local Code Display name", "definition": "This is defined locally.", "min": 0, "max": "1", "mustSupport": true }, { "path": "Specimen.type.text", "short": "Display text", "definition": "This is the laboratory defined display text for the actual test result, if different from the code display names.", "min": 0, "max": "1", "mustSupport": true }, { "path": "Specimen.subject", "short": "Patient", "definition": "Patient.", "synonym": [ "Patient" ], "min": 1, "max": "1", "type": [ { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/patient-uslab-uslabpatient" }, { "code": "Reference", "profile": "http://hl7.org/fhir/Profile/patient-uslab-uslabphpatient" } ], "mustSupport": true }, { "path": "Specimen.accessionIdentifier", "synonym": [ "Filler ID" ], "min": 1, "max": "1", "type": [ { "code": "Identifier" } ], "mustSupport": true }, { "path": "Specimen.accessionIdentifier.use", "min": 1, "max": "1", "type": [ { "code": "code" } ], "fixedCode": "official", "mustSupport": true }, { "path": "Specimen.accessionIdentifier.system", "short": "Filler URI", "definition": "Filler URI.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.accessionIdentifier.value", "short": "Filler Identifier", "definition": "Filler Identifier.", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.collection", "min": 1, "max": "1", "mustSupport": true }, { "path": "Specimen.collection.collected[x]", "min": 1, "max": "1", "condition": [ "inv-2" ], "constraint": [ { "key": "inv-2", "name": "datetime to day", "severity": "error", "human": "Datetime must be at least to the day.", "xpath": "f:matches(.,/\\d{4}-[01]\\d-[0-3])/)" } ], "mustSupport": true }, { "path": "Specimen.collection.bodySiteCodeableConcept", "min": 0, "max": "1", "type": [ { "code": "CodeableConcept" } ], "mustSupport": true }, { "path": "Specimen.collection.bodySiteCodeableConcept.coding", "slicing": { "discriminator": [ "system" ], "ordered": false, "rules": "open" } }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding", "name": "USLabSNOMEDCTCoding", "short": "SNOMED-CT coding if available", "definition": "SNOMED-CT coding if available.", "synonym": [ "Snomed Code" ], "min": 0, "max": "1", "mustSupport": true, "binding": { "name": "USLabSpecimenbodySite[x]", "isExtensible": true, "conformance": "required", "description": "Codes to describe the Specimen Collection Body site", "referenceReference": { "reference": "http://hl7.org/fhir/vs/body-site" } } }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.system" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.system", "short": "SNOMED-CT Coding System", "definition": "SNOMED-CT Coding System.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "fixedUri": "http://snomed.info/sct", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.code" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.code", "short": "SNOMED-CT", "definition": "SNOMED Clinical Terms is a systematically organized computer processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting.", "min": 1, "max": "1", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.display" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.display", "short": "SNOMED-CT Display Name", "definition": "The SNOMED-CT 'preferred name' is preferred although any SNOMED-CT 'synonym' can also be used. ( ihtsdo.org/snomed-ct/).", "min": 0, "max": "1", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding", "name": "USLabLocalCoding", "synonym": [ "Local" ], "min": 0, "max": "1", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.system" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.system", "short": "Local Coding System", "definition": "This is defined locally.", "min": 1, "max": "1", "type": [ { "code": "uri" } ], "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.code" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.code", "short": "Local Code", "definition": "Local Code.", "min": 1, "max": "1", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.coding.display" } ], "path": "Specimen.collection.bodySiteCodeableConcept.coding.display", "short": "local Code Display name", "definition": "This is defined locally.", "min": 0, "max": "1", "mustSupport": true }, { "extension": [ { "url": "http://hl7.org/fhir/ExtensionDefinition/profile-display-hint", "valueString": "Specimen.type.text" } ], "path": "Specimen.collection.bodySiteCodeableConcept.text", "short": "Display text", "definition": "This is the laboratory defined display text for the actual test result, if different from the code display names.", "min": 0, "max": "1", "mustSupport": true } ] } }