US Core Implementation Guide
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US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core DiagnosticReport Profile for Report and Note Exchange

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note Version: 8.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreDiagnosticReportProfileNoteExchange
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.21

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core DiagnosticReport Profile for Report and Note Exchange inherits from the FHIR DiagnosticReport resource; refer to it for scope and usage definitions. This profile sets minimum expectations for searching and fetching Diagnostic Reports and Notes using the DiagnosticReport resource. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present in the resource and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. Before reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of the US Core DiagnosticReport Profile for Report and Note exchange and the US Core DocumentReference Profile.

Example Usage Scenarios:

The following are example usage scenarios for this profile:

  • Query for a specific clinical test result, such as an electrocardiogram (ECG)
  • Query for a specific imaging test result
  • Query for a specific Radiology note (e.g., 84178-3 Interventional Radiology Note)
  • Query for a category of reports (e.g., all Cardiology reports)

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each Diagnostic Report Must Have:

  1. a status
  2. a category*
  3. a code describing the type of report
  4. a patient
  5. the diagnostically relevant time (known as the "effective time" and typically the time of the procedure)*

*This element has the following constraint: SHALL be present if status is 'partial', 'preliminary', 'final', 'amended', 'corrected', or 'appended'.

Each Diagnostic Report Must Support:

  1. encounter associated with DiagnosticReport
  2. instant the report was released
  3. an author (actor) producing the report
  4. a results interpreter*
  5. a reference to one or more test results
  6. a reference to one or more images
  7. a reference to the full report (presentedForm)

* see guidance below

Profile Specific Implementation Guidance:

  • See Clinical Notes
  • The DiagnosticReport.category binding Must Support, at a minimum, the US Core DiagnosticReport Category Codes of Cardiology, Radiology, and Pathology. Other categories may be supported.
    • It is up to the data source to categorize the documents they send. Therefore, Clients need to understand that data categorization is somewhat subjective, and the categorization applied by the source may not align with the Client's expectations. Any linkages between specific LOINC codes and the LP-type codes may be used as guidance. If LOINC develops a hierarchy or categorization to align these concepts, US Core will be updated.
  • A Server will return how a customer has categorized their reports at a particular site. Categorization of reports is not consistent across sites. (e.g., a system may categorize an orthopedic note as cardiology.)
  • For Diagnostic Imaging Reports systems SHOULD support using the subset of LOINC codes defined in CONF-DIR-19 in *HL7 Implementation Guide for CDA Release 2: Imaging Integration, Levels 1, 2, and 3, Basic Imaging Reports in CDA and DICOM Diagnostic Imaging Reports (DIR) - Universal Realm, Release 1.0.

  • *The profile elements DiagnosticReport.performer and DiagnosticReport.resultsInterpreter communicate the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

  • Diagnostic imaging results in visual images requiring interpretation and clinical test results/reports may also reference images as part of the report. There is no single approach for accessing imaging studies alongside clinical data using a single authorization flow to give patients and providers access to the images.

    • The DiagnosticReport.media.link element SHOULD be used to support links to various patient-friendly content, such as jpg images of x-rays (see the DiagnosticReport Chest X-ray Report Example).
    • The DiagnosticReport.imagingStudy element SHOULD be used to support exchange with systems that can view DICOM studies, series, and SOP instances referenced in the ImagingStudy resource.
    • Alternatively, systems can use business identifiers such as accession numbers in the identifier element to access the source images from external sources.

    The Argonauts 2023 SMART Imaging Access project is testing an approach to access imaging studies using a single authorization flow

Usage:

Changes since version 7.0.0:

  • The data elements list has changed

    • Formal Views of Profile Content

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

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... status SC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category S 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    .... category:us-core S 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    ... code S 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes

    ... subject S 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) The subject of the report - usually, but not always, the patient
    ... encounter S 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ... effective[x] SC 0..1 Diagnostically relevant time (typically the time of the procedure)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued S 0..1 instant DateTime this version was made
    ... performer S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    ... resultsInterpreter S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) Observations
    ... presentedForm S 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[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()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: 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
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ele-1: All FHIR elements must have a @value or children
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    ele-1: All FHIR elements must have a @value or children
    .... category:us-core SΣ 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


    ele-1: All FHIR elements must have a @value or children
    ... code SΣ 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes


    ele-1: All FHIR elements must have a @value or children
    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
    ele-1: All FHIR elements must have a @value or children
    ... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ele-1: All FHIR elements must have a @value or children
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
    ele-1: All FHIR elements must have a @value or children
    .... effectiveDateTime dateTime
    ... issued SΣ 0..1 instant DateTime this version was made
    ele-1: All FHIR elements must have a @value or children
    ... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) Responsible Diagnostic Service
    ele-1: All FHIR elements must have a @value or children
    ... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile) Primary result interpreter
    ele-1: All FHIR elements must have a @value or children
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observations
    ele-1: All FHIR elements must have a @value or children
    ... presentedForm S 0..* Attachment Entire report as issued
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[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()
    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:us-core SΣ 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


    ... code SΣ 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) The subject of the report - usually, but not always, the patient
    ... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued SΣ 0..1 instant DateTime this version was made
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    ... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    ... specimen 0..* Reference(Specimen) Specimens this report is based on
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) 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 S 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG
    DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
    http://hl7.org/fhir/ValueSet/clinical-findings
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

    Differential View

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... status SC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category S 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    .... category:us-core S 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

    ... code S 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes

    ... subject S 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) The subject of the report - usually, but not always, the patient
    ... encounter S 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ... effective[x] SC 0..1 Diagnostically relevant time (typically the time of the procedure)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued S 0..1 instant DateTime this version was made
    ... performer S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    ... resultsInterpreter S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) Observations
    ... presentedForm S 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings (Differential)

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: 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
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ele-1: All FHIR elements must have a @value or children
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    ele-1: All FHIR elements must have a @value or children
    .... category:us-core SΣ 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


    ele-1: All FHIR elements must have a @value or children
    ... code SΣ 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes


    ele-1: All FHIR elements must have a @value or children
    ... subject SΣ 1..1 Reference(US Core Patient Profile) The subject of the report - usually, but not always, the patient
    ele-1: All FHIR elements must have a @value or children
    ... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ele-1: All FHIR elements must have a @value or children
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
    ele-1: All FHIR elements must have a @value or children
    .... effectiveDateTime dateTime
    ... issued SΣ 0..1 instant DateTime this version was made
    ele-1: All FHIR elements must have a @value or children
    ... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) Responsible Diagnostic Service
    ele-1: All FHIR elements must have a @value or children
    ... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile) Primary result interpreter
    ele-1: All FHIR elements must have a @value or children
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) Observations
    ele-1: All FHIR elements must have a @value or children
    ... presentedForm S 0..* Attachment Entire report as issued
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[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()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraintsdoco
    .. DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    us-core-10: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    ... 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: CommonLanguages (preferred): A human language.

    Additional BindingsPurpose
    AllLanguages Max Binding
    ... text 0..1 Narrative Text summary of the resource, for human interpretation
    ... contained 0..* Resource Contained, inline Resources
    ... extension 0..* Extension Additional content defined by implementations
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier Σ 0..* Identifier Business identifier for report
    ... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
    ... status ?!SΣC 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    ... Slices for category SΣ 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


    .... category:us-core SΣ 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


    ... code SΣ 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes

    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Group | Device | US Core Location Profile) The subject of the report - usually, but not always, the patient
    ... encounter SΣ 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    ... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of the procedure)
    .... effectiveDateTime dateTime S
    .... effectivePeriod Period
    ... issued SΣ 0..1 instant DateTime this version was made
    ... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    ... resultsInterpreter SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    ... specimen 0..* Reference(Specimen) Specimens this report is based on
    ... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) 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 S 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DiagnosticReport.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    DiagnosticReport.statusrequiredDiagnosticReportStatus
    http://hl7.org/fhir/ValueSet/diagnostic-report-status
    from the FHIR Standard
    DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
    http://hl7.org/fhir/ValueSet/diagnostic-service-sections
    from the FHIR Standard
    DiagnosticReport.category:us-corerequiredUSCoreDiagnosticReportCategory
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
    from this IG
    DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
    http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
    from this IG
    DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
    http://hl7.org/fhir/ValueSet/clinical-findings
    from the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    us-core-10errorDiagnosticReporteffective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
    : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists()

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Quick Start

    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Scopes Format section for a description of the SMART scopes syntax.
    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a Server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple patients.

    US Core Scopes

    Servers providing access to clniical note data SHALL support these US Core SMART Scopes:

    Mandatory Search Parameters:

    The following search parameters and search parameter combinations SHALL be supported:

    1. SHALL support searching for all diagnosticreports for a patient using the patient search parameter:

      GET [base]/DiagnosticReport?patient={Type/}[id]

      Example:

      1. GET [base]/DiagnosticReport?patient=1137192

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient (how to search by reference)

    2. SHALL support searching using the combination of the patient and category search parameters:

      GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]

      Example:

      1. GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code specified in US Core DiagnosticReport Category Codes (how to search by reference and how to search by token)

    3. SHALL support searching using the combination of the patient and code search parameters:
      • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)

      GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}

      Example:

      1. GET [base]/DiagnosticReport?patient=1032702&code=http://loinc.org|24323-8

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token)

    4. SHALL support searching using the combination of the patient and category and date search parameters:
      • including support for these date comparators: gt,lt,ge,le
      • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

      GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5&date=ge2010-01-14T00:00:00Z

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and a category code specified in US Core DiagnosticReport Category Codes (how to search by reference and how to search by token and how to search by date)

    Optional Search Parameters:

    The following search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and status search parameters:
      • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

      GET [base]/DiagnosticReport?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

      Example:

      1. GET [base]/DiagnosticReport?patient=1137192&status=completed

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and status (how to search by reference and how to search by token)

    2. SHOULD support searching using the combination of the patient and code and date search parameters:
      • including optional support for OR search on code (e.g.code={system|}[code],{system|}[code],...)
      • including support for these date comparators: gt,lt,ge,le
      • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

      GET [base]/DiagnosticReport?patient={Type/}[id]&code={system|}[code]{,{system|}[code],...}&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/DiagnosticReport?patient=f201&code=http://loinc.org|24323-8&date=ge2019-01-14T00:00:00Z

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and date and report code(s). SHOULD support search by multiple report codes. (how to search by reference and how to search by token and how to search by date)

    3. SHOULD support searching using the combination of the patient and category and _lastUpdated search parameters:
      • including support for these _lastUpdated comparators: gt,lt,ge,le
      • including optional support for AND search on _lastUpdated (e.g._lastUpdated=[date]&_lastUpdated=[date]]&...)

      GET [base]/DiagnosticReport?patient={Type/}[id]&category={system|}[code]&_lastUpdated={gt|lt|ge|le}[date]{&_lastUpdated={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/DiagnosticReport?patient=f201&category=http://loinc.org|LP29684-5&_lastUpdated=ge2010-01-14T00:00:00Z

      Implementation Notes: Fetches a bundle of all DiagnosticReport resources for the specified patient and a category code specified in US Core DiagnosticReport Category Codes and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. (how to search by reference and how to search by token and how to search by date)