QI-Core Implementation Guide
4.1.0 - release

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## Resource Profile: QICoreDiagnosticReportNote

Defining URL: | http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note
Version: | 4.1.0
Name: | QICoreDiagnosticReportNote
Status: | Draft as of 8/22/18
Definition: | 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.
Publisher: | http://www.hl7.org/Special/committees/cqi/index.cfm
Source Resource: | XML / JSON / Turtle

The official URL for this profile is:

    http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-diagnosticreport-note

Usage

See the patterns page for implementation and usage patterns.

### Examples

Radiology Diagnostic Report Example

### Formal Views of Profile Content

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

- Text Summary
- Differential Table
- Snapshot Table
- Snapshot Table (Must Support)
- All

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

- QICoreLocation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location)
- QICoreImmunizationRecommendation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-immunizationrec)
- QICoreMedicationRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest)
- QICoreServiceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest)
- QICorePatient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICoreEncounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)
- QICorePractitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICoreOrganization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICoreSpecimen (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-specimen)
- QICoreObservation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation)
- QICoreImagingStudy (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-imagingstudy)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
diagnosticReport-locationPerformed |  | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
value[x]:valueReference |  | 1..1 | Reference(QICoreLocation) | Value of extension
basedOn |  | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested
subject | S | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient
encounter | S | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered
effective[x] | S | 1..1 | dateTime, Period | Time of the report or note
issued | S | 0..1 | instant | DateTime this version was made
performer | S | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service
specimen |  | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on
result | S | 0..* | Reference(QICoreObservation) | Observations
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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) Max Binding: AllLanguages: A human language.
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
diagnosticReport-locationPerformed |  | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
value[x]:valueReference |  | 1..1 | Reference(QICoreLocation) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient
encounter | S Σ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered
effective[x] | S Σ | 1..1 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen |  | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on
result | S | 0..* | Reference(QICoreObservation) | Observations
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | 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 | S | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
presentedForm | S | 0..* | Attachment | Entire report as issued
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
status | ?!Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required)
category | Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible)
code | Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | Σ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient
encounter | Σ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered
effective[x] | Σ | 1..1 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | Σ | 0..1 | instant | DateTime this version was made
performer | Σ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service
result |  | 0..* | Reference(QICoreObservation) | Observations
imagingStudy |  | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report
conclusion |  | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentation for this format

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Mandatory: 0 element (1 nested mandatory element)
Must-Support: 9 elements

Structures

This structure refers to these other structures:

- QICoreLocation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-location)
- QICoreImmunizationRecommendation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-immunizationrec)
- QICoreMedicationRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest)
- QICoreServiceRequest (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-servicerequest)
- QICorePatient (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient)
- QICoreEncounter (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter)
- QICorePractitioner (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-practitioner)
- QICoreOrganization (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-organization)
- QICoreSpecimen (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-specimen)
- QICoreObservation (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation)
- QICoreImagingStudy (http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-imagingstudy)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
diagnosticReport-locationPerformed |  | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
value[x]:valueReference |  | 1..1 | Reference(QICoreLocation) | Value of extension
basedOn |  | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested
subject | S | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient
encounter | S | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered
effective[x] | S | 1..1 | dateTime, Period | Time of the report or note
issued | S | 0..1 | instant | DateTime this version was made
performer | S | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service
specimen |  | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on
result | S | 0..* | Reference(QICoreObservation) | Observations
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | Reference to full details of imaging associated with the diagnostic report
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | USCoreDiagnosticReportProfileNoteExchange | US Core Diagnostic Report Profile for Report and Note exchange
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) Max Binding: AllLanguages: A human language.
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
diagnosticReport-locationPerformed |  | 0..1 | Reference(Location) | Location Performed URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..0 |  |
url |  | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
value[x]:valueReference |  | 1..1 | Reference(QICoreLocation) | Value of extension
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
identifier | Σ | 0..* | Identifier | Business identifier for report
basedOn |  | 0..* | Reference(CarePlan | QICoreImmunizationRecommendation | QICoreMedicationRequest | NutritionOrder | QICoreServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | final + Binding: DiagnosticReportStatus (required)
category | S Σ | 1..* | CodeableConcept | Service category Binding: US Core DiagnosticReport Category (extensible)
code | S Σ | 1..1 | CodeableConcept | US Core Report Code Binding: US Core Diagnosticreport Report And Note Codes (extensible): LOINC codes
subject | S Σ | 1..1 | Reference(QICorePatient) | The subject of the report - usually, but not always, the patient
encounter | S Σ | 0..1 | Reference(QICoreEncounter) | Health care event when test ordered
effective[x] | S Σ | 1..1 |  | Time of the report or note
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 0..1 | instant | DateTime this version was made
performer | S Σ | 0..* | Reference(QICorePractitioner | QICoreOrganization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | CareTeam) | Primary result interpreter
specimen |  | 0..* | Reference(QICoreSpecimen) | Specimens this report is based on
result | S | 0..* | Reference(QICoreObservation) | Observations
imagingStudy | S | 0..* | Reference(QICoreImagingStudy) | 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 | S | 0..1 | string | Clinical conclusion (interpretation) of test results
conclusionCode | S | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: SNOMEDCTClinicalFindings (preferred): This value set includes all the "Clinical finding" SNOMED CT codes - concepts where concept is-a 404684003 (Clinical finding (finding)).
presentedForm | S | 0..* | Attachment | Entire report as issued
Documentation for this format

Other representations of profile: CSV, Excel, Schematron

#### Terminology Bindings

Path | Conformance | ValueSet
DiagnosticReport.language | preferred | CommonLanguages Max Binding: AllLanguages
DiagnosticReport.status | required | DiagnosticReportStatus
DiagnosticReport.category | extensible | USCoreDiagnosticReportCategory
DiagnosticReport.code | extensible | USCoreDiagnosticreportReportAndNoteCodes
DiagnosticReport.conclusionCode | preferred | SNOMEDCTClinicalFindings

#### Constraints

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.extension:locationPerformed | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | DiagnosticReport.extension:locationPerformed | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
ele-1 | error | DiagnosticReport.extension:locationPerformed.value[x]:valueReference | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
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.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()) |