HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot
HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1
0.1.0 - STU 1 Ballot
HL7 FHIR® Implementation Guide: Ophthalmology Retinal, Release 1, published by HL7 International - Patient Care WG. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/fhir-eyecare-ig/ and changes regularly. See the Directory of published versions
| Defining URL: | http://hl7.org/fhir/uv/eyecare/StructureDefinition/diagnostic-report-base |
| Version: | 0.1.0 |
| Name: | OphthalDiagnosticReport |
| Title: | Ophthalmic diagnostic test report |
| Status: | Draft as of 2022-06-24 01:58:09+0000 |
| Definition: | Base profile specifically constrained for describing ophthalmic reports |
| Publisher: | HL7 International - Patient Care WG |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
http://hl7.org/fhir/uv/eyecare/StructureDefinition/diagnostic-report-base
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Fixed Value: 2 elements
Slices
This structure defines the following Slices:
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
  category | S | 1..* | CodeableConcept | Service category |
  Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system |
  coding:ophthalCode | 1..1 | Coding | Code defined by a terminology system | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 394594003 | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
  id | Σ | 0..1 | string | 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 | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
 category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
 id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding | SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | ||||
| coding:ophthalCode | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 394594003 | ||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
 text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
 effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 | Σ | 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 | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| category | Σ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. |
| coding | Σ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system |
| Documentation for this format | ||||
This structure is derived from DiagnosticReport
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Fixed Value: 2 elements
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DiagnosticReport
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |
| category | S | 1..* | CodeableConcept | Service category |
| Slices for coding | S | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system |
| coding:ophthalCode | 1..1 | Coding | Code defined by a terminology system | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 394594003 | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport | 0..* | DiagnosticReport | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports | |||||
| id | Σ | 0..1 | string | 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 | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required): The status of the diagnostic report. | ||||
| category | SΣ | 1..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| Slices for coding | SΣ | 1..* | Coding | Code defined by a terminology system Slice: Unordered, Open by value:code, value:system | ||||
| coding:ophthalCode | Σ | 1..1 | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 394594003 | ||||
| display | Σ | 0..1 | string | Representation defined by the system | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| code | Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports. | ||||
| subject | Σ | 0..1 | Reference(Patient | Group | Device | Location) | The subject of the report - usually, but not always, the patient | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Health care event when test ordered | ||||
| effective[x] | Σ | 0..1 | Clinically relevant time/time-period for report | |||||
| effectiveDateTime | dateTime | |||||||
| effectivePeriod | Period | |||||||
| issued | Σ | 0..1 | instant | DateTime this version was made | ||||
| performer | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | 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 | Σ | 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 | 0..* | Attachment | Entire report as issued | |||||
| Documentation for this format | ||||||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet |
| DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages |
| DiagnosticReport.status | required | DiagnosticReportStatus |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodes |
| DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes |
| DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings |
| Id | Grade | Path | 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 | DiagnosticReport.meta | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.implicitRules | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.language | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.identifier | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.basedOn | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.status | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.category.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.category.coding | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.category.coding:ophthalCode.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.system | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.version | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.display | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.coding:ophthalCode.userSelected | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.category.text | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.code | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.subject | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.encounter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.effective[x] | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.issued | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.performer | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.resultsInterpreter | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.specimen | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.result | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.imagingStudy | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media.extension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.media.extension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.media.modifierExtension | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| ele-1 | error | DiagnosticReport.media.comment | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.media.link | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.conclusion | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ele-1 | error | DiagnosticReport.presentedForm | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
IG © 2020+ HL7 International - Patient Care WG. Package hl7.fhir.uv.eyecare#0.1.0 based on FHIR 4.0.1. Generated 2022-06-24
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