US Quality Core Implementation Guide
0.1.0 - cibuild United States of America flag

US Quality Core Implementation Guide, published by ASTP. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/FHIR/us-quality-core/ and changes regularly. See the Directory of published versions

Resource Profile: US Quality Core DiagnosticReport Profile for Laboratory Results Reporting

Official URL: http://fhir.org/guides/astp/us-quality-core/StructureDefinition/us-quality-core-diagnosticreport-lab Version: 0.1.0
Active as of 2023-08-01 Computable Name: USQualityCoreDiagnosticReportLab

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

Usage

See the patterns page for implementation and usage patterns.

Examples

Blood Panel Example

USCDI+ Quality Elements:

  • status: (USCDI+ Quality) (USCDI) registered \| partial \| preliminary \| final +
  • category: (USCDI+ Quality) (USCDI) Service category
  • category:LaboratorySlice: (USCDI+ Quality) (USCDI) Service category
  • code: (USCDI+ Quality) (USCDI) US Core Laboratory Report Order Code
  • effective[x]: (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
  • result: (USCDI+ Quality) (USCDI) Observations

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..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn 0..* Reference(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... effective[x] SΣC 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI) When the report was released
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) Responsible Diagnostic Service
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations

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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦6.1.0 US Core v6.1

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-8 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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..* Reference(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status 1..1 code (USCDI+ Quality) (USCDI) registered | partial | preliminary | final +
... Slices for category Σ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice Σ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
... subject 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... effective[x] Σ 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) Responsible Diagnostic Service
... result 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... 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(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI) When the report was released
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) 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(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) 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 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 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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦6.1.0 US Core v6.1
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-8 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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn 0..* Reference(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... effective[x] SΣC 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI) When the report was released
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) Responsible Diagnostic Service
... result S 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations

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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦6.1.0 US Core v6.1

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-8 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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

Differential View

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn 0..* Reference(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status 1..1 code (USCDI+ Quality) (USCDI) registered | partial | preliminary | final +
... Slices for category Σ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice Σ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
... subject 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... effective[x] Σ 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) Responsible Diagnostic Service
... result 0..* Reference(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DiagnosticReport.category Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
Constraints: us-core-8, us-core-9
... 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(US Quality Core CarePlan | US Quality Core ImmunizationRecommendation | US Quality Core MedicationRequest | US Quality Core NutritionOrder | US Quality Core ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI+ Quality) (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI+ Quality) (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (preferred): Codes for diagnostic service sections.
.... category:LaboratorySlice SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) Service category
Binding: DiagnosticServiceSectionCodes (preferred): 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://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept (USCDI+ Quality) (USCDI) US Core Laboratory Report Order Code
Binding: US Core Laboratory Test Codes (extensible): LOINC codes
... subject SΣ 1..1 Reference(US Quality Core Patient) (USCDI) The subject of the report - usually, but not always, the patient
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI+ Quality) (USCDI) Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant (USCDI) When the report was released
... performer SΣ 0..* Reference(US Quality Core Practitioner | US Quality Core PractitionerRole | US Quality Core Organization) (USCDI) 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(US Quality Core Laboratory Result Observation) (USCDI+ Quality) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) 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 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 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 preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.category:LaboratorySlice Base preferred Diagnostic Service Section Codes 📦4.0.1 FHIR Std.
DiagnosticReport.code Base extensible US Core Laboratory Test Codes 📦6.1.0 US Core v6.1
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-8 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()
us-core-9 error DiagnosticReport issued 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 issued.exists()

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

 

Other representations of profile: CSV, Excel, Schematron