Cancer Pathology Data Sharing
2.0.0-ballot - STU 2 Ballot United States of America flag

Cancer Pathology Data Sharing, published by HL7 International / Orders and Observations and College of American Pathologists. This guide is not an authorized publication; it is the continuous build for version 2.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. 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: 2.0.0-ballot
Standards status: Trial-use Computable Name: USPathologyDiagnosticReport

This DiagnosticReport Profile captures data for a report parsed from an eCP Form.

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.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-3: 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
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
dom-6: A resource should have narrative for robust management
us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
ele-1: All FHIR elements must have a @value or children
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
... identifier Σ 0..* Identifier Business identifier for report
ele-1: All FHIR elements must have a @value or children
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
ele-1: All FHIR elements must have a @value or children
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


ele-1: All FHIR elements must have a @value or children
.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


ele-1: All FHIR elements must have a @value or children
... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes


ele-1: All FHIR elements must have a @value or children
... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
ele-1: All FHIR elements must have a @value or children
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
ele-1: All FHIR elements must have a @value or children
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
ele-1: All FHIR elements must have a @value or children
path-reporting-1: effectiveDateTime SHALL include the month and day
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
ele-1: All FHIR elements must have a @value or children
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) (USCDI) Responsible Diagnostic Service
ele-1: All FHIR elements must have a @value or children
... resultsInterpreter SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
ele-1: All FHIR elements must have a @value or children
... specimen S 0..* Reference(US Pathology Specimen) Specimens this report is based on
ele-1: All FHIR elements must have a @value or children
... result S 0..* Reference(US Pathology Observation) (USCDI) Observations
ele-1: All FHIR elements must have a @value or children
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
ele-1: All FHIR elements must have a @value or children
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
ele-1: All FHIR elements must have a @value or children
ext-1: Must have either extensions or value[x], not both
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
ele-1: All FHIR elements must have a @value or children
... presentedForm S 1..* Attachment SDC form, HTML render, and/or PDF
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes

Constraints

IdGradePath(s)DetailsRequirements
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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
path-reporting-1errorDiagnosticReport.effective[x]effectiveDateTime SHALL include the month and day
: $this is DateTime implies $this.toString().length() >= 10
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()

 

Other representations of profile: CSV, Excel, Schematron