PACIO Personal Functioning and Engagement Implementation Guide
1.9.0 - STU1 United States of America flag

PACIO Personal Functioning and Engagement Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.9.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions

Resource Profile: Personal Functioning and Engagement Narrative History of Status

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-narrative-history-of-status Version: 1.9.0
Draft as of 2024-04-16 Computable Name: PFENarrativeHistoryOfStatus

An exchange of a narrative summary regarding the most recent prior status immediately preceding the current admission, illness, or exacerbation for a patient. The use of this profile is encouraged in the absence of formal prior level assessments. For formal assessments conducted with for example, an assessment instrument, use the collection and single observation profiles defined in this IG to capture assessment data.

Example Usage Scenarios:

The following are example usage scenarios for this Profile:

  • Query for a narrative of a patient’s prior functioning and engagement.
  • Record or update prior functioning and engagement narratives for a Patient.

Mandatory and Must Support Data Elements

The following data elements must always be present or must be supported if the data is present in the sending system (Must Support definition). They are presented below with a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Personal Functioning and Engagement Narrative History of Status must have:

  1. a status
  2. a category code of “functioning”
  3. a code describing the type of narrative
  4. a patient
  5. the point in time or period covered by the narrative
  6. who wrote the narrative
  7. a narrative about the patient’s prior functioning and engagement

Each Personal Functioning and Engagement Narrative History of Status must support:

  1. the location the narrative was written
  2. the level of assistance required by the patient during the time or period covered by the narrative
  3. an additional category value(s) specifying the specific health or health-related domain that this narrative is related to*
  4. the encounter the report occurred within
  5. instant the report was released

* see guidance below

Profile specific implementation guidance:

  • *When a health or health-related domain is specified as an additional category value, DiagnosticReport.code SHOULD be drawn from the corresponding domain-based value set as discussed on the domains page.

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..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... category 1..* CodeableConcept Service category
... category:functioning S 1..1 CodeableConcept Service category
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
..... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... category:PFEDomain S 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... effective[x] 1..1 dateTime, Period Diagnostically relevant time (typically the time of the procedure)
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... presentedForm 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
.... category:PFEDomain SΣ 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Health care event when test ordered
... effective[x] SΣC 1..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile) Observations
... media SΣ 0..* BackboneElement Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) Reference to the image source
... presentedForm S 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
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.category:functioningexamplePattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... id Σ 0..1 id 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 ?!SΣC 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... category:PFEDomain SΣ 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Health care event when test ordered
... effective[x] SΣC 1..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 1..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* 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 SΣ 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 SΣ 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 S 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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.category:functioningexamplePattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... category 1..* CodeableConcept Service category
... category:functioning S 1..1 CodeableConcept Service category
Required Pattern: At least the following
.... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
..... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
..... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
..... display 1..1 string Representation defined by the system
Fixed Value: Functioning
... category:PFEDomain S 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... effective[x] 1..1 dateTime, Period Diagnostically relevant time (typically the time of the procedure)
... performer 1..* Reference(US Core Practitioner Profile | US Core PractitionerRole Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... presentedForm 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
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
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
.... category:PFEDomain SΣ 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Health care event when test ordered
... effective[x] SΣC 1..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 1..* Reference(US Core Practitioner Profile | US Core Organization Profile) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Test Result Profile | US Core Observation Imaging Result Profile) Observations
... media SΣ 0..* BackboneElement Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) Reference to the image source
... presentedForm S 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
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.category:functioningexamplePattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... id Σ 0..1 id 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
... event-location S 0..1 Reference(US Core Location Profile) An extension to indicate where the documented information was collected.
URL: http://hl7.org/fhir/StructureDefinition/event-location profiled by http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/event-location
... assistance-required S 0..1 CodeableConcept An extension to indicate the level of assistance required for a patient during an assessment.
URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/assistance-required
Binding: LOINC Answer List LL4309-2 (extensible)
... 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 ?!SΣC 1..1 code Should have the value 'final' when the observation is complete and there are no further actions needed. Otherwise, another value from the value set may appropriately be used.
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required)
.... category:functioning SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-functioning-cs
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: functioning
...... display 1..1 string Representation defined by the system
Fixed Value: Functioning
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
.... category:PFEDomain SΣ 0..* CodeableConcept Service category
Binding: Personal Functioning and Engagement Category Value Set (required)
... code SΣ 1..1 CodeableConcept US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) Health care event when test ordered
... effective[x] SΣC 1..1 Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant DateTime this version was made
... performer SΣ 1..* Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile | US Core Organization Profile S) The person who performed the assessment. The preferred way to specify the performer is to use the PractitionerRole resource to provide both the practitioner and organization.
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* 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 SΣ 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 SΣ 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 S 1..* Attachment The narrative text describing the patient's history of status.

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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.category:functioningexamplePattern: functioning("Functioning")
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:PFEDomainrequiredPFECategoryVS (a valid code from Personal Functioning and Engagement Category)
http://hl7.org/fhir/us/pacio-pfe/ValueSet/pfe-category-vs
from this IG
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron

Notes:

The syntax used to describe the interactions below is described here.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code = mental_functions (how to search by reference and how to search by token)

  2. SHALL support searching using the combination of the patient and code search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&code=http://loinc.org|11332-4
    2. GET [base]/DiagnosticReport?patient=1134281&code=http://loinc.org|11332-4,http://loinc.org|10158-4

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and code(s). SHOULD support search by multiple report codes. The DiagnosticReport code parameter searches `DiagnosticReport.code only. (how to search by reference and how to search by token)

  3. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]DiagnosticReport?patient=555580&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&date=ge2018-03-14T00:00:00Z

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code = mental_functions (how to search by reference and how to search by token and how to search by date)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and category and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DiagnosticReport?patient=1134281&category=http://hl7.org/fhir/us/pacio-pfe/CodeSystem/pfe-category-cs|mental_functions&status=final

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and category mental_functions and status final (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and code and date search parameters:
    • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]DiagnosticReport?patient=555580&code=http://loinc.org|11332-4&date=ge2019-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)