Cancer Pathology Data Sharing
1.0.0 - CI Build United States of America flag

Cancer Pathology Data Sharing, published by HL7 Orders and Observations Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/cancer-reporting/ and changes regularly. See the Directory of published versions

Resource Profile: US Pathology Diagnostic Report

Official URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-diagnostic-report Version: 1.0.0
Active as of 2022-07-06 Computable Name: USPathologyDiagnosticReport

Copyright/Legal:

It is expected that labs will populate dateTimes with the most specific time information known when sending to EHRs (YYYY-MM-DD).

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... subject 1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... effective[x] SI0..1dateTime S, PeriodDiagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
... resultsInterpreter S0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... status ?!SΣI1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣI0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status ?!ΣI1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category Σ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core Σ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code Σ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... encounter Σ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] ΣI0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(US Pathology Specimen)Specimens this report is based on
... result 0..*Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile)Observations
... media Σ0..*BackboneElementKey images associated with this report
.... link Σ1..1Reference(Media)Reference to the image source
... presentedForm 0..*AttachmentEntire report as issued

doco Documentation for this format

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... subject 1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... effective[x] SI0..1dateTime S, PeriodDiagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
... resultsInterpreter S0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*USCoreDiagnosticReportProfileNoteExchangeA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(US Pathology Service Request)What was requested
... status ?!SΣI1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ1..*CodeableConceptService category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ0..*CodeableConceptService category
Binding: US Core Diagnostic Report Category Codes (required)
... code SΣ1..1CodeableConceptUS Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ1..1Reference(US Core Patient Profile)The subject of the report - usually, but not always, the patient
... encounter SΣ0..1Reference(US Core Encounter Profile)Health care event when test ordered
... effective[x] SΣI0..1Diagnostically relevant time (typically the time of the procedure)
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTimedateTime S
.... effectivePeriodPeriod
... issued SΣ0..1instantDateTime this version was made
... performer SΣ0..*Reference(US Core Practitioner Profile | US Core Organization Profile | US Pathology Related Practitioner Roles | US Core CareTeam Profile)Responsible Diagnostic Service
... resultsInterpreter SΣ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen S0..*Reference(US Pathology Specimen)Specimens this report is based on
... result S0..*Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Test Result Profile S | US Core Observation Imaging Result Profile S)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media SΣ0..*BackboneElementKey images associated with this report
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... comment 0..1stringComment about the image (e.g. explanation)
.... link SΣ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical conclusion (interpretation) of test results
... conclusionCode 0..*CodeableConceptCodes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
DiagnosticReport.languagepreferredCommonLanguages
Max Binding: AllLanguages
DiagnosticReport.statusrequiredDiagnosticReportStatus
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings

Constraints

IdGradePathDetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6Best PracticeDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
: (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()
ele-1errorDiagnosticReport.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.basedOnAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category:us-coreAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.effective[x]All FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10
ele-1errorDiagnosticReport.issuedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.performerAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.resultsInterpreterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.specimenAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.resultAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.imagingStudyAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.mediaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.media.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.media.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.media.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.media.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.media.commentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.media.linkAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.conclusionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.conclusionCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.presentedFormAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())