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

Resource Profile: OCT macula Diagnostic Report

Defining URL:http://hl7.org/fhir/uv/eyecare/StructureDefinition/diagnostic-report-oct-macula
Version:0.1.0
Name:OphthalDiagnosticReportOCTMacula
Title:OCT macula Diagnostic Report
Status:Draft as of 2022-06-24 01:58:09+0000
Definition:

The DiagnosticReport profile for an OCT macula

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-oct-macula

Formal Views of Profile Content

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

This structure is derived from OphthalDiagnosticReport

Summary

Mandatory: 4 elements
Must-Support: 4 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.code.coding is sliced based on the values of value:code, value:system

This structure is derived from OphthalDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*OphthalDiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... code
.... Slices for coding 1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:maculaCode S1..1CodingCode defined by a terminology system
...... system S1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code S1..1codeSymbol in syntax defined by the system
Fixed Value: 57119-0
... result S0..*Reference(Observation | OCT macula Observations)Observations

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*OphthalDiagnosticReportA 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:ophthalCode Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 394594003
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:maculaCode SΣ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: 57119-0
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Patient | Group | Device | Location)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(Observation | OCT macula Observations)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*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 Σ1..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 0..*AttachmentEntire report as issued

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*OphthalDiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... category Σ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... coding Σ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
... code Σ1..1CodeableConceptName/Code for this diagnostic report
.... coding:maculaCode Σ1..1CodingCode defined by a terminology system
..... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 57119-0
... result 0..*Reference(Observation | OCT macula Observations)Observations

doco Documentation for this format

This structure is derived from OphthalDiagnosticReport

Summary

Mandatory: 4 elements
Must-Support: 4 elements
Fixed Value: 2 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DiagnosticReport.code.coding is sliced based on the values of value:code, value:system

Differential View

This structure is derived from OphthalDiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*OphthalDiagnosticReportA Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... code
.... Slices for coding 1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:maculaCode S1..1CodingCode defined by a terminology system
...... system S1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... code S1..1codeSymbol in syntax defined by the system
Fixed Value: 57119-0
... result S0..*Reference(Observation | OCT macula Observations)Observations

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..*OphthalDiagnosticReportA 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(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)What was requested
... status ?!Σ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.

... category SΣ1..*CodeableConceptService category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:ophthalCode Σ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version Σ0..1stringVersion of the system - if relevant
...... code Σ1..1codeSymbol in syntax defined by the system
Fixed Value: 394594003
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... code Σ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ1..*CodingCode defined by a terminology system
Slice: Unordered, Open by value:code, value:system
..... coding:maculaCode SΣ1..1CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ1..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
...... version Σ0..1stringVersion of the system - if relevant
...... code SΣ1..1codeSymbol in syntax defined by the system
Fixed Value: 57119-0
...... display Σ0..1stringRepresentation defined by the system
...... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Patient | Group | Device | Location)The subject of the report - usually, but not always, the patient
... encounter Σ0..1Reference(Encounter)Health care event when test ordered
... effective[x] Σ0..1Clinically relevant time/time-period for report
.... effectiveDateTimedateTime
.... effectivePeriodPeriod
... issued Σ0..1instantDateTime this version was made
... performer Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Responsible Diagnostic Service
... resultsInterpreter Σ0..*Reference(Practitioner | PractitionerRole | Organization | CareTeam)Primary result interpreter
... specimen 0..*Reference(Specimen)Specimens this report is based on
... result S0..*Reference(Observation | OCT macula Observations)Observations
... imagingStudy 0..*Reference(ImagingStudy)Reference to full details of imaging associated with the diagnostic report
... media Σ0..*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 Σ1..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 0..*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.codepreferredLOINCDiagnosticReportCodes
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()
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.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.category.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.category.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCode.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.category.coding:ophthalCode.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.category.coding:ophthalCode.systemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCode.versionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCode.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCode.displayAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.coding:ophthalCode.userSelectedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.category.textAll 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.code.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.code.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.code.codingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCodeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCode.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDiagnosticReport.code.coding:maculaCode.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDiagnosticReport.code.coding:maculaCode.systemAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCode.versionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCode.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCode.displayAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.coding:maculaCode.userSelectedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDiagnosticReport.code.textAll 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())
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())