QI-Core Implementation Guide
7.0.2 - STU 7 United States of America flag

QI-Core Implementation Guide, published by HL7 International / Clinical Quality Information. This guide is not an authorized publication; it is the continuous build for version 7.0.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-qi-core/ and changes regularly. See the Directory of published versions

Resource Profile: QICore DiagnosticReport Profile for Report and Note Exchange

Official URL: http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note Version: 7.0.2
Standards status: Trial-use Maturity Level: 4 Computable Name: QICoreDiagnosticReportNote

Profile of DiagnosticReport for Note exchange for decision support/quality metrics. Defines the core set of elements and extensions for quality rule and measure authors.

"Must Have", "QI Elements" and "primary code path" are defined in the QI-Core Must Support section.
Must Have:
  • subject: (QI) The subject of the report - usually, but not always, the patient
  • status: (QI)registered | partial | preliminary | final +
  • category: (QI) Service Category
  • code: (QI) QI-Core Report Code
QI Elements:
  • effective[x]: (QI) Diagnostically relevant time (typically the time of the procedure)
  • result: (QI) Observations
  • imagingStudy: (QI) Reference to full details of imaging associated with the diagnostic report
  • issued: (QI) DateTime this version was made
  • media: (QI) Key images associated with this report
  • encounter: (QI) Health care event when test ordered
  • performer: (QI) Responsible Diagnostic Service
Primary code path: code
(PCPath) This element is the primary code path for this resource CQL Retrieve

Usage

See the patterns page for implementation and usage patterns.

Examples

Radiology Diagnostic Report Example

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(QICore Patient) (QI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] SΣC 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (QI) DateTime this version was made
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization) (QI) Responsible Diagnostic Service
... result S 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (QI) 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦7.0.0 US Core v7.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0

Constraints

Id Grade Path(s) Description Expression
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 **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-10 error DiagnosticReport effective[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()

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category 1..* CodeableConcept (QI) Service Category
Slice: Unordered, Open by pattern:$this
... code Σ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... encounter 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] Σ 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant (QI) DateTime this version was made
... performer 0..* Reference(QICore Practitioner | QICore Organization) (QI) Responsible Diagnostic Service
... result 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media 0..* BackboneElement (QI) Key images associated with this report

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (QI) 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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(QICore Patient) (QI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] SΣC 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (QI) DateTime this version was made
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization) (QI) 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 S 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (QI) 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦7.0.0 US Core v7.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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 **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-10 error DiagnosticReport effective[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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
.... category:us-core SΣ 0..* CodeableConcept Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(QICore Patient) (QI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] SΣC 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (QI) DateTime this version was made
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization) (QI) Responsible Diagnostic Service
... result S 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (QI) 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦7.0.0 US Core v7.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0

Constraints

Id Grade Path(s) Description Expression
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 **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-10 error DiagnosticReport effective[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()

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category 1..* CodeableConcept (QI) Service Category
Slice: Unordered, Open by pattern:$this
... code Σ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... encounter 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] Σ 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued 0..1 instant (QI) DateTime this version was made
... performer 0..* Reference(QICore Practitioner | QICore Organization) (QI) Responsible Diagnostic Service
... result 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media 0..* BackboneElement (QI) Key images associated with this report

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-10
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... 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 ?!SΣC 1..1 code (QI)registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (QI) 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): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... code SΣ 1..1 CodeableConcept (QI) QI-Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(QICore Patient) (QI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(QICore Encounter) (QI) Health care event when test ordered
... effective[x] SΣC 0..1 (QI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (QI) DateTime this version was made
... performer SΣ 0..* Reference(QICore Practitioner | QICore Organization) (QI) 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 S 0..* Reference(QICore Laboratory Result Observation | QICore Observation Clinical Result) (QI) Observations
... imagingStudy 0..* Reference(QICore ImagingStudy) (QI) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (QI) 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 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DiagnosticReport.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
DiagnosticReport.category Base example Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦7.0.0 US Core v7.0
DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦7.0.0 US Core v7.0
DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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 **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
us-core-10 error DiagnosticReport effective[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