Qi-Core Implementation Guide (Release 2.1 Draft)

D.4.1 StructureDefinition: qicore-diagnosticreport

Examples:

Blood Panel Example

D.4.1.1 Formal Views of Profile Content

The official URL for this profile is:

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

This profile builds on DiagnosticReport.

This profile was published on Mon Aug 21 00:00:00 UTC 2017 as a draft by Health Level Seven International (Clinical Quality Information - QICore).

Description of Profiles, Differentials, and Snapshots.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... diagnosticReport-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... valueReference 1..1Reference(QICore-Location)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan), Reference(QICore-ImmunizationRecommendation), Reference(MedicationRequest), Reference(NutritionOrder), Reference(ProcedureRequest), Reference(QICore-ReferralRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..1CodeableConceptService category
Binding: Diagnostic Service Section Codes (preferred)
... code SΣ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred)
... subject SΣ1..1Reference(QICore-Patient)The subject of the report - usually, but not always, the patient
... context SΣ0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodClinically relevant time/time-period for report
... issued SΣ1..1instantDateTime this version was released
... performer SΣI0..*BackboneElementParticipants in producing the report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... role Σ0..1CodeableConceptType of performer
Binding: Procedure Performer Role Codes (example)
.... actor SΣ1..1Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner), Reference(US Core Organization Profile)Practitioner or Organization participant
... specimen 0..*Reference(QICore-Specimen)Specimens this report is based on
... result S0..*Reference(QICore-Observation)Observations - simple, or complex nested groups
... imagingStudy S0..*Reference(QICore-ImagingStudy), Reference(ImagingManifest)Reference to full details of imaging associated with the diagnostic report
... image SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (preferred)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport I0..*A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... diagnosticReport-locationPerformed I0..1Reference(Location)Location Performed
URL: http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed
.... id 0..1stringxml:id (or equivalent in JSON)
.... url 1..1uri"http://hl7.org/fhir/StructureDefinition/diagnosticReport-locationPerformed"
.... valueReference 1..1Reference(QICore-Location)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier for report
... basedOn 0..*Reference(CarePlan), Reference(QICore-ImmunizationRecommendation), Reference(MedicationRequest), Reference(NutritionOrder), Reference(ProcedureRequest), Reference(QICore-ReferralRequest)What was requested
... status ?!SΣ1..1coderegistered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... category SΣ1..1CodeableConceptService category
Binding: Diagnostic Service Section Codes (preferred)
... code SΣ1..1CodeableConceptName/Code for this diagnostic report
Binding: LOINC Diagnostic Report Codes (preferred)
... subject SΣ1..1Reference(QICore-Patient)The subject of the report - usually, but not always, the patient
... context SΣ0..1Reference(QICore-Encounter), Reference(EpisodeOfCare)Health care event when test ordered
... effective[x] SΣ1..1dateTime, PeriodClinically relevant time/time-period for report
... issued SΣ1..1instantDateTime this version was released
... performer SΣI0..*BackboneElementParticipants in producing the report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... role Σ0..1CodeableConceptType of performer
Binding: Procedure Performer Role Codes (example)
.... actor SΣ1..1Reference(http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner), Reference(US Core Organization Profile)Practitioner or Organization participant
... specimen 0..*Reference(QICore-Specimen)Specimens this report is based on
... result S0..*Reference(QICore-Observation)Observations - simple, or complex nested groups
... imagingStudy S0..*Reference(QICore-ImagingStudy), Reference(ImagingManifest)Reference to full details of imaging associated with the diagnostic report
... image SΣI0..*BackboneElementKey images associated with this report
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... comment 0..1stringComment about the image (e.g. explanation)
.... link Σ1..1Reference(Media)Reference to the image source
... conclusion 0..1stringClinical Interpretation of test results
... codedDiagnosis S0..*CodeableConceptCodes for the conclusion
Binding: SNOMED CT Clinical Findings (preferred)
... presentedForm S0..*AttachmentEntire report as issued

doco Documentation for this format

 

D.4.1.2 Terminology Bindings

Terminology Bindings

PathNameConformanceValueSet
DiagnosticReport.languageCommon LanguagesextensibleCommon Languages
DiagnosticReport.statusDiagnosticReportStatusrequiredDiagnosticReportStatus
DiagnosticReport.categoryDiagnostic Service Section CodespreferredDiagnostic Service Section Codes
DiagnosticReport.codeLOINC Diagnostic Report CodespreferredLOINC Diagnostic Report Codes
DiagnosticReport.performer.roleProcedure Performer Role CodesexampleProcedure Performer Role Codes
DiagnosticReport.codedDiagnosisSNOMED CT Clinical FindingspreferredSNOMED CT Clinical Findings

D.4.1.3 Constraints

Constraints

IdPathDetailsRequirements
dom-2DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1DiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4DiagnosticReportIf 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-3DiagnosticReportIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.extensionAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ext-1DiagnosticReport.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1DiagnosticReport.performerAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1DiagnosticReport.imageAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())