abstractbaseDefinitioncopyrightdescriptionexperimentalfhirVersionjurisdiction
jurisdiction[0]kindnamepublisherpurposestatustitletypeurl| Left: | US Core DiagnosticReport Profile for Report and Note Exchange (http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note) |
| Right: | US Core DiagnosticReport Profile for Report and Note Exchange (http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note) |
| Name | Value | Comments | |
|---|---|---|---|
| abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/DiagnosticReport | ||
| copyright | |||
| description | The US Core DiagnosticReport Profile for Report and Note Exchange inherits from the FHIR [DiagnosticReport](https://hl7.org/fhir/R4/diagnosticreport.html) resource; refer to it for scope and usage definitions. This profile sets minimum expectations for searching and fetching Diagnostic Reports and Notes using the DiagnosticReport resource. It specifies which core elements, extensions, vocabularies, and value sets **SHALL** be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. Before reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of the US Core DiagnosticReport Profile for Report and Note exchange and the US Core DocumentReference Profile. | ||
| experimental | |||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
| jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreDiagnosticReportProfileNoteExchange | ||
| publisher | HL7 International / Cross-Group Projects | ||
| purpose | |||
| status | active | ||
| title | US Core DiagnosticReport Profile for Report and Note Exchange | ||
| type | DiagnosticReport | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | ||
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 DiagnosticReport | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 | C | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: us-core-10 | |||||||||
 id | 0..1 | id | Logical id of this artifact | 0..1 | id | Logical id of this artifact | |||||||||||
| meta | 0..1 | Meta | Metadata about the resource | 0..1 | Meta | Metadata about the resource | |||||||||||
| implicitRules | 0..1 | uri | A set of rules under which this content was created | 0..1 | uri | A set of rules under which this content was created | |||||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | 0..* | Extension | Extensions that cannot be ignored | 0..* | Extension | Extensions that cannot be ignored | |||||||||||
| identifier | 0..* | Identifier | Business identifier for report | 0..* | Identifier | Business identifier for report | |||||||||||
| basedOn | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | 0..* | Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | What was requested | |||||||||||
| status | C | 1..1 | code | registered | partial | preliminary | final + Binding: ?? (required) | C | 1..1 | code | registered | partial | preliminary | final + Binding: ?? (required) | |||||||||
| Slices for category | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: ?? (example): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:$this Binding: ?? (example): Codes for diagnostic service sections. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||||||||
| code | 1..1 | CodeableConcept | US Core Report Code Binding: ?? (extensible): LOINC codes | 1..1 | CodeableConcept | US Core Report Code Binding: ?? (extensible): LOINC codes | |||||||||||
| subject | 1..1 | Reference(US Core Patient Profile | Group | US Core Device Profile | US Core Location Profile) | The subject of the report - usually, but not always, the patient | 1..1 | Reference(US Core Patient Profile | Group | US Core Device Profile | US Core Location Profile) | The subject of the report - usually, but not always, the patient | |||||||||||
| encounter | 0..1 | Reference(US Core Encounter Profile) | Encounter associated with DiagnosticReport | 0..1 | Reference(US Core Encounter Profile) | Encounter associated with DiagnosticReport | |||||||||||
| effective[x] | C | 0..1 | dateTime , Period | Diagnostically relevant time (typically the time of the procedure) | C | 0..1 | dateTime , Period | Diagnostically relevant time (typically the time of the procedure) | |||||||||
| issued | 0..1 | instant | DateTime this version was made | 0..1 | instant | DateTime this version was made | |||||||||||
| performer | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core PractitionerRole Profile | US Core CareTeam Profile) | Responsible Diagnostic Service | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core PractitionerRole Profile | US Core CareTeam Profile) | Responsible Diagnostic Service | |||||||||||
| resultsInterpreter | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) | Primary result interpreter | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) | Primary result interpreter | |||||||||||
| specimen | 0..* | Reference(Specimen) | Specimens this report is based on | 0..* | Reference(Specimen) | Specimens this report is based on | |||||||||||
| result | 0..* | Reference(US Core Observation Clinical Result Profile | US Core Laboratory Result Observation Profile | Observation) | Observations | 0..* | Reference(US Core Observation Clinical Result Profile | US Core Laboratory Result Observation Profile | Observation) | Observations | |||||||||||
| imagingStudy | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | 0..* | Reference(ImagingStudy) | Reference to full details of imaging associated with the diagnostic report | |||||||||||
| media | 0..* | BackboneElement | Key images associated with this report | 0..* | BackboneElement | Key images associated with this report | |||||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||||
| comment | 0..1 | string | Comment about the image (e.g. explanation) | 0..1 | string | Comment about the image (e.g. explanation) | |||||||||||
| link | 1..1 | Reference(Media) | Reference to the image source | 1..1 | Reference(Media) | Reference to the image source | |||||||||||
| conclusion | 0..1 | string | Clinical conclusion (interpretation) of test results | 0..1 | string | Clinical conclusion (interpretation) of test results | |||||||||||
| conclusionCode | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: ?? (example): Diagnosis codes provided as adjuncts to the report. | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: ?? (example): Diagnosis codes provided as adjuncts to the report. | |||||||||||
| presentedForm | 0..* | Attachment | Entire report as issued | 0..* | Attachment | Entire report as issued | |||||||||||
| Documentation for this format | |||||||||||||||||