HL7 FHIR Costa Rica - Reportes de Imágenes Médicas
0.0.1-draft - ci-build

HL7 FHIR Costa Rica - Reportes de Imágenes Médicas, published by Iniciativa HL7 Costa Rica. This guide is not an authorized publication; it is the continuous build for version 0.0.1-draft built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cr/imaging-report/ and changes regularly. See the Directory of published versions

## Resource Profile: CR Diagnostic Report

Official URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-diagnostic-report | Version:
Standards status: Draft | Maturity Level: 0 | Computable Name: CRDiagnosticReport
Copyright/Legal: Utilizado con permiso de HL7 International, todos los derechos reservados Licencia Creative Commons

Perfil unificado para reportes diagnósticos en Costa Rica: estudios de imagen (Rayos X, CT, MRI, Mamografía, Ultrasonido), laboratorio, patología, etc. Regla común: reporte final, soporte para Composition, y extensiones clínicas.

Usages:

- Examples for this Profile: DiagnosticReport/diagnostic-report-xray-with-dicom-example

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.

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport(5.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: dgr-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid Constraints: ext-1
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | S Σ | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:radiology | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
effective[x] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 1..1 | instant | DateTime this version was made
performer | S Σ | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner) | Primary result interpreter
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:radiology | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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.implicitRules, DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.category:radiology, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.study, DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport(5.0.0) | 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
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history
identifier | S | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | S | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Fixed Value: final
Slices for category |  | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system
category:radiology |  | 1..1 | CodeableConcept | Service category
coding |  |  |  |
system |  | 1..1 | uri | Identity of the terminology system Required Pattern: https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections
code |  | 0..1 | code | Symbol in syntax defined by the system Required Pattern: RAD
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report
issued | S | 1..1 | instant | DateTime this version was made
performer | S | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter |  | 0..* | Reference(Practitioner) | Primary result interpreter
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport(5.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: dgr-1
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: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid Constraints: ext-1
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | S Σ | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:radiology | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url Constraints: ext-1
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url Constraints: ext-1
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ C | 0..1 | code | Symbol in syntax defined by the system Required Pattern: RAD
display | Σ C | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S Σ | 1..1 | Reference(Patient) | 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] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 1..1 | instant | DateTime this version was made
performer | S Σ | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on
result | C | 0..* | Reference(Observation) | Observations
note |  | 0..* | Annotation | Comments about the diagnostic report
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
supportingInfo |  | 0..* | BackboneElement | Additional information supporting the diagnostic report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
type |  | 1..1 | CodeableConcept | Supporting information role code Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
reference |  | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference
media | Σ | 0..* | BackboneElement | Key images or data associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data source
composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure
conclusion |  | 0..1 | markdown | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:radiology | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.supportingInfo.​type | Base | example | hl7VS-VS-observationType | 📍3.0.0 | THO v7.1
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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, DiagnosticReport.implicitRules, DiagnosticReport.language, DiagnosticReport.text, DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.category:radiology, DiagnosticReport.category:radiology.extension, DiagnosticReport.category:radiology.coding, DiagnosticReport.category:radiology.coding.extension, DiagnosticReport.category:radiology.coding.system, DiagnosticReport.category:radiology.coding.version, DiagnosticReport.category:radiology.coding.code, DiagnosticReport.category:radiology.coding.display, DiagnosticReport.category:radiology.coding.userSelected, DiagnosticReport.category:radiology.text, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.media, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension, DiagnosticReport.media.comment, DiagnosticReport.media.link, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode, DiagnosticReport.presentedForm | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.category:radiology.extension, DiagnosticReport.category:radiology.coding.extension, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReport

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 8 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- ServiceRequest (http://hl7.org/fhir/StructureDefinition/ServiceRequest|5.0.0)
- Patient (http://hl7.org/fhir/StructureDefinition/Patient|5.0.0)
- Practitioner (http://hl7.org/fhir/StructureDefinition/Practitioner|5.0.0)
- Organization (http://hl7.org/fhir/StructureDefinition/Organization|5.0.0)
- ImagingStudy (http://hl7.org/fhir/StructureDefinition/ImagingStudy|5.0.0)

Extensions

This structure refers to these extensions:

- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.category

Maturity: 0

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport(5.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: dgr-1
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid Constraints: ext-1
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | S Σ | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:radiology | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S Σ | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
effective[x] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 1..1 | instant | DateTime this version was made
performer | S Σ | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner) | Primary result interpreter
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:radiology | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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.implicitRules, DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.category:radiology, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.study, DiagnosticReport.conclusionCode | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  | 0..* | DiagnosticReport(5.0.0) | 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
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history
identifier | S | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | S | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Fixed Value: final
Slices for category |  | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system
category:radiology |  | 1..1 | CodeableConcept | Service category
coding |  |  |  |
system |  | 1..1 | uri | Identity of the terminology system Required Pattern: https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections
code |  | 0..1 | code | Symbol in syntax defined by the system Required Pattern: RAD
code | S | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S | 1..1 | Reference(Patient) | The subject of the report - usually, but not always, the patient
effective[x] | S | 1..1 | dateTime, Period | Clinically relevant time/time-period for report
issued | S | 1..1 | instant | DateTime this version was made
performer | S | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter |  | 0..* | Reference(Practitioner) | Primary result interpreter
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport | C | 0..* | DiagnosticReport(5.0.0) | A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports Constraints: dgr-1
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: AllLanguages (required): IETF language tag for a human language
Additional Bindings | Purpose
CommonLanguages | Starter
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
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url Constraints: ext-1
extension:dicomInstanceUid |  | 0..* | (Complex) | Información de acceso a imágenes DICOM URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid Constraints: ext-1
extension:impression |  | 0..* | Reference(Observation | Condition) | Impresión clínica del reporte URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression Constraints: ext-1
extension:recommendation |  | 0..* | Reference(CarePlan | ServiceRequest) | Recomendaciones clínicas URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation Constraints: ext-1
extension:patientHistory |  | 0..* | Reference(Observation) | Historial del paciente relevante URL: https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1
identifier | S Σ | 1..* | Identifier | Business identifier for report
basedOn | S | 0..* | Reference(ServiceRequest) | What was requested
status | ?!S Σ | 1..1 | code | registered | partial | preliminary | modified | final | amended | corrected | appended | cancelled | entered-in-error | unknown Binding: DiagnosticReportStatus (required): The status of the diagnostic report. Fixed Value: final
Slices for category | Σ | 1..* | CodeableConcept | Service category Slice: Unordered, Open by value:coding.system Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
category:radiology | Σ | 1..1 | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): HL7 V2 table 0074
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url Constraints: ext-1
coding | Σ | 0..* | Coding | Code defined by a terminology system
id |  | 0..1 | id | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url Constraints: ext-1
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: https://hl7.or.cr/fhir/terminology/CodeSystem/cr-diagnostic-service-sections
version | Σ | 0..1 | string | Version of the system - if relevant
code | Σ C | 0..1 | code | Symbol in syntax defined by the system Required Pattern: RAD
display | Σ C | 0..1 | string | Representation defined by the system
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept
code | S Σ | 1..1 | CodeableConcept | Name/Code for this diagnostic report Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes (extensible): Tipo de reporte diagnóstico (todos los tipos: imaging, lab, patología, etc.)
subject | S Σ | 1..1 | Reference(Patient) | 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] | S Σ | 1..1 |  | Clinically relevant time/time-period for report
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
issued | S Σ | 1..1 | instant | DateTime this version was made
performer | S Σ | 1..* | Reference(Practitioner | Organization) | Responsible Diagnostic Service
resultsInterpreter | Σ | 0..* | Reference(Practitioner) | Primary result interpreter
specimen |  | 0..* | Reference(Specimen) | Specimens this report is based on
result | C | 0..* | Reference(Observation) | Observations
note |  | 0..* | Annotation | Comments about the diagnostic report
study |  | 0..* | Reference(ImagingStudy) | Reference to full details of an analysis associated with the diagnostic report
supportingInfo |  | 0..* | BackboneElement | Additional information supporting the diagnostic report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
type |  | 1..1 | CodeableConcept | Supporting information role code Binding: Hl7VSVSObservationType (3.0.0) (example): The code value for the role of the supporting information in the diagnostic report.
reference |  | 1..1 | Reference(Procedure | Observation | DiagnosticReport | Citation) | Supporting information reference
media | Σ | 0..* | BackboneElement | Key images or data associated with this report
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Constraints: ext-1
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1
comment |  | 0..1 | string | Comment about the image or data (e.g. explanation)
link | Σ | 1..1 | Reference(DocumentReference) | Reference to the image or data source
composition | C | 0..1 | Reference(Composition) | Reference to a Composition resource for the DiagnosticReport structure
conclusion |  | 0..1 | markdown | Clinical conclusion (interpretation) of test results
conclusionCode |  | 0..* | CodeableConcept | Codes for the clinical conclusion of test results Binding: https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings (required)
presentedForm |  | 0..* | Attachment | Entire report as issued
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DiagnosticReport.language | Base | required | All Languages | 📍5.0.0 | FHIR Std.
DiagnosticReport.status | Base | required | Diagnostic Report Status | 📍5.0.0 | FHIR Std.
DiagnosticReport.category | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.category:radiology | Base | example | Diagnostic Service Section Codes | 📍5.0.0 | FHIR Std.
DiagnosticReport.code | Base | extensible | https://hl7.or.cr/fhir/terminology/ValueSet/cr-report-codes | Not State | Unknown
DiagnosticReport.supportingInfo.​type | Base | example | hl7VS-VS-observationType | 📍3.0.0 | THO v7.1
DiagnosticReport.conclusionCode | Base | required | https://hl7.or.cr/fhir/terminology/ValueSet/cr-diagnostic-findings | Not State | Unknown

#### Constraints

Id | Grade | Path(s) | Description | Expression
dgr-1 | error | DiagnosticReport | When a Composition is referenced in `Diagnostic.composition`, all Observation resources referenced in `Composition.entry` must also be referenced in `Diagnostic.entry` or in the references Observations in `Observation.hasMember` | `composition.exists() implies (composition.resolve().section.entry.reference.where(resolve() is Observation) in (result.reference|result.reference.resolve().hasMember.reference))`
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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, DiagnosticReport.implicitRules, DiagnosticReport.language, DiagnosticReport.text, DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.identifier, DiagnosticReport.basedOn, DiagnosticReport.status, DiagnosticReport.category, DiagnosticReport.category:radiology, DiagnosticReport.category:radiology.extension, DiagnosticReport.category:radiology.coding, DiagnosticReport.category:radiology.coding.extension, DiagnosticReport.category:radiology.coding.system, DiagnosticReport.category:radiology.coding.version, DiagnosticReport.category:radiology.coding.code, DiagnosticReport.category:radiology.coding.display, DiagnosticReport.category:radiology.coding.userSelected, DiagnosticReport.category:radiology.text, DiagnosticReport.code, DiagnosticReport.subject, DiagnosticReport.encounter, DiagnosticReport.effective[x], DiagnosticReport.issued, DiagnosticReport.performer, DiagnosticReport.resultsInterpreter, DiagnosticReport.specimen, DiagnosticReport.result, DiagnosticReport.note, DiagnosticReport.study, DiagnosticReport.supportingInfo, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.supportingInfo.type, DiagnosticReport.supportingInfo.reference, DiagnosticReport.media, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension, DiagnosticReport.media.comment, DiagnosticReport.media.link, DiagnosticReport.composition, DiagnosticReport.conclusion, DiagnosticReport.conclusionCode, DiagnosticReport.presentedForm | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | DiagnosticReport.extension, DiagnosticReport.extension:dicomInstanceUid, DiagnosticReport.extension:impression, DiagnosticReport.extension:recommendation, DiagnosticReport.extension:patientHistory, DiagnosticReport.modifierExtension, DiagnosticReport.category:radiology.extension, DiagnosticReport.category:radiology.coding.extension, DiagnosticReport.supportingInfo.extension, DiagnosticReport.supportingInfo.modifierExtension, DiagnosticReport.media.extension, DiagnosticReport.media.modifierExtension | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DiagnosticReport

Summary

Mandatory: 7 elements(1 nested mandatory element)
Must-Support: 8 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- ServiceRequest (http://hl7.org/fhir/StructureDefinition/ServiceRequest|5.0.0)
- Patient (http://hl7.org/fhir/StructureDefinition/Patient|5.0.0)
- Practitioner (http://hl7.org/fhir/StructureDefinition/Practitioner|5.0.0)
- Organization (http://hl7.org/fhir/StructureDefinition/Organization|5.0.0)
- ImagingStudy (http://hl7.org/fhir/StructureDefinition/ImagingStudy|5.0.0)

Extensions

This structure refers to these extensions:

- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/dicom-instance-uid
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-impression
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-recommendation
- https://hl7.or.cr/fhir/imaging-report/StructureDefinition/cr-hl7idr-patient-history

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.category

Maturity: 0

Other representations of profile: CSV, Excel, Schematron