Canadian Baseline
1.1.0 - CI Build
Canadian Baseline, published by HL7 Canada - FHIR Implementation Work Group. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Canada/ca-baseline/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-diagnosticreportnote | Version: 1.1.0 | |||
Draft as of 2022-06-08 | Computable Name: DiagnosticReportNoteProfile |
Proposed constraints and extensions on the Diagnostic Report Resource to support collection of diagnostic report information for reports and notes. Generated as a first step toward creating a set of Canadian Baseline FHIR profiles.
This profile initially put forth placeholders for the value sets used in category and code. Further work is required to determine if this profile should align to the value set in use in US Core (https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-category.html and https://www.hl7.org/fhir/us/core/ValueSet-us-core-diagnosticreport-report-and-note-codes.html) or if a Canadian value set needs to be created.
</blockquote> </div> This profile sets minimum expectations to support collection of diagnostic report information for reports and notes. Generated as a first step toward creating a set of Canadian Baseline FHIR profiles. It identifies which core elements, constraints and value sets SHALL be present in the resource instance when using this profile. This profile defines core localisation concepts for use in an Canadian context. ## Mandatory Data Elements All elements or attributes defined in FHIR have cardinality as part of their definition - a minimum number of required appearances and a maximum number. Most elements in FHIR specification have a minimum cardinality of **0**, which means that they may be missing from a resource when it is exchanged between systems. **Required elements:** * status of the diagnostic report * category of the diagnostic report * code that describes the diagnostic report * subject of the report * time when report was created ## Must Support Data Elements Some elements are labeled as MustSupport meaning that implementations that produce or consume resources SHALL provide "support" for the element in some meaningful way (see [Must Support](https://build.fhir.org/ig/HL7-Canada/ca-baseline/general-guidance.html#must-support) definition). Following elements are marked as Must Support in the Canadian DiagnosticReport Note profile to aid record matching in databases. **Must Support elements:** * status of the report * category that classifies the report * code that describes the diagnostic report * subject of the report * healthcare event this report is about * time when report was created * time when report was issued * diagnostic service responsible for report * Media that are part of this report * Attachments that are part of this report ## Usage Note
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |
status | S | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. |
category | S | 1..* | CodeableConcept | Service category |
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report |
subject | S | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to |
encounter | S | 0..1 | Reference(Encounter Profile) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Time of report or note |
issued | S | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available |
performer | S | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service |
media | S | 0..* | BackboneElement | Key images associated with this report |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. |
category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
subject | SΣ | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to |
encounter | SΣ | 0..1 | Reference(Encounter Profile) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Time of report or note | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available |
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | Σ | 1..1 | Reference(Media) | Reference to the image source |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. | ||||
category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to | ||||
encounter | SΣ | 0..1 | Reference(Encounter Profile) | Health care event when test ordered | ||||
effective[x] | SΣ | 1..1 | Time of report or note | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | 0..* | Reference(Observation) | Observations | |||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from DiagnosticReport
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |
status | S | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. |
category | S | 1..* | CodeableConcept | Service category |
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report |
subject | S | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to |
encounter | S | 0..1 | Reference(Encounter Profile) | Health care event when test ordered |
effective[x] | S | 1..1 | dateTime, Period | Time of report or note |
issued | S | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available |
performer | S | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service |
media | S | 0..* | BackboneElement | Key images associated with this report |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. |
category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. |
subject | SΣ | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to |
encounter | SΣ | 0..1 | Reference(Encounter Profile) | Health care event when test ordered |
effective[x] | SΣ | 1..1 | Time of report or note | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
issued | SΣ | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available |
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service |
media | SΣ | 0..* | BackboneElement | Key images associated with this report |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
link | Σ | 1..1 | Reference(Media) | Reference to the image source |
presentedForm | S | 0..* | Attachment | Entire report as issued |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DiagnosticReport | 0..* | DiagnosticReport | DiagnosticReport for Report and Note Profile | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business identifier for report | ||||
basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||
status | ?!SΣ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): Codes providing the status of a DiagnosticReport. | ||||
category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
code | SΣ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
subject | SΣ | 1..1 | Reference(Patient Profile) | The patient that the diagnostic report refers to | ||||
encounter | SΣ | 0..1 | Reference(Encounter Profile) | Health care event when test ordered | ||||
effective[x] | SΣ | 1..1 | Time of report or note | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
issued | SΣ | 0..1 | instant | Date/Time this version of the DiagnosticReport was made available | ||||
performer | SΣ | 0..* | Reference(Practitioner Profile (General) | Organization Profile) | Responsible Diagnostic Service | ||||
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter | ||||
specimen | 0..* | Reference(Specimen) | Specimens this report is based on | |||||
result | 0..* | Reference(Observation) | Observations | |||||
imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||
media | SΣ | 0..* | BackboneElement | Key images associated with this report | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
comment | 0..1 | string | Comment about the image (e.g. explanation) | |||||
link | Σ | 1..1 | Reference(Media) | Reference to the image source | ||||
conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||
conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report. | |||||
presentedForm | S | 0..* | Attachment | Entire report as issued | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes (a valid code from LOINC)http://hl7.org/fhir/ValueSet/report-codes from the FHIR Standard | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
dom-4 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
dom-5 | error | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DiagnosticReport | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DiagnosticReport
Summary
Mandatory: 3 elements
Must-Support: 10 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron