US Core Implementation Guide
10.0.0-ballot - STU 10 Ballot United States of America flag

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 10.0.0-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: 10.0.0-ballot
Standards status: Trial-use Maturity Level: 5 Computable Name: USCoreDiagnosticReportProfileNoteExchange
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.21

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.

US Core Maturity: 5

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 category1
  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)2

Each Diagnostic Report Must Support:

  1. encounter associated with DiagnosticReport
  2. instant the report was released
  3. an author (actor) producing the report3
  4. a results interpreter3
  5. a reference to one or more test results
  6. a reference to the full report (presentedForm)

Additional USCDI Requirements:

These Additional USCDI Requirements elements are not Mandatory or Must Support but are required for ONC Health IT certification testing and are included in the formal definition of the profile and the DiagnosticReport examples.

  1. a business identifier for the report4
  2. a reference to the order the report fulfills4
  3. a reference to one or more imaging studies4
  4. a reference to one or more images4

1,2,3,4 see guidance below

Profile Specific Implementation Guidance

This section provides detailed implementation guidance for the US Core Profile to support implementation and certification.

  • See Clinical Notes
  • 2DiagnosticReport.effective[x] has the following constraint: SHALL be present if status is 'partial', 'preliminary', 'final', 'amended', 'corrected', or 'appended'.§
  • 1The 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 can 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 listed in Table 4: LOINC® Document Type Codes in HL7 Standard for CDA® Release 2: Imaging Integration; Basic Imaging Reports in CDA and DICOM, Release 1§
  • 3The 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.

USCDI Diagnostic Imaging Reference Data Element

  • 4Diagnostic imaging results in visual images requiring interpretation, and clinical test results and reports can 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. For the USCDI Diagnostic Imaging Reference Data Element, this profile marks four elements as Additional USCDI Requirements. A Server supports all four; they address different parts of the problem and none replaces another.

    • The DiagnosticReport.imagingStudy element SHOULD be used to support exchange with systems that can view DICOM (Digital Imaging and Communications in Medicine) studies, series, and SOP (Service-Object Pair) instances referenced in the ImagingStudy resource.§ The reference is to the US Core ImagingStudy Profile, which carries the identifiers and the endpoint information needed to locate or access the study. This is the principal mechanism for meeting the Diagnostic Imaging Reference Data Element.
    • 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).§ Supporting DiagnosticReport.media.link is not a substitute for meeting the Diagnostic Imaging Reference Data Element.
    • Systems can also use business identifiers such as accession numbers in DiagnosticReport.identifier to access the source images from external sources. The same accession number appears on the order as ServiceRequest.identifier and on the study as ImagingStudy.identifier.
      • The DiagnosticReport.basedOn element connects the DiagnosticReport to the originating order in the EHR. Systems that initiate the order SHOULD use this element when reporting the results,§ because imaging identifiers such as the accession number originate with the order and are what connect the order, the report, and the imaging study.

    The Argonaut SMART Imaging Access project defined an approach to access imaging studies using a single authorization flow.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 9.0.0:

  • The data elements list has changed

    • Formal Views of Profile Content

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

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    DiagnosticReport.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    DiagnosticReport.identifier This element is included in summaries. 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element is a modifier element. This element must be supported. This element is included in summaries. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. This element is included in summaries. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. This element is included in summaries. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

    DiagnosticReport.code This element must be supported. This element is included in summaries. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. This element is included in summaries. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. This element is included in summaries. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. This element is included in summaries. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media This element is included in summaries. 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    DiagnosticReport.media.link This element is included in summaries. 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.presentedForm This element must be supported. 0..* Attachment Entire report as issued

    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 example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.identifier 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element must be supported. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.
    DiagnosticReport.code This element must be supported. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.link 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.presentedForm This element must be supported. 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()
    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.id This element is included in summaries. 0..1 id Logical id of this artifact
    DiagnosticReport.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    DiagnosticReport.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    DiagnosticReport.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    DiagnosticReport.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
    DiagnosticReport.contained 0..* Resource Contained, inline Resources
    DiagnosticReport.extension 0..* Extension Additional content defined by implementations
    DiagnosticReport.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    DiagnosticReport.identifier This element is included in summaries. 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element is a modifier element. This element must be supported. This element is included in summaries. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. This element is included in summaries. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. This element is included in summaries. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

    DiagnosticReport.code This element must be supported. This element is included in summaries. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. This element is included in summaries. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. This element is included in summaries. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. This element is included in summaries. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.specimen 0..* Reference(Specimen) Specimens this report is based on
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media This element is included in summaries. 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.id 0..1 string Unique id for inter-element referencing
    DiagnosticReport.media.extension 0..* Extension Additional content defined by implementations
    DiagnosticReport.media.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    DiagnosticReport.media.comment 0..1 string Comment about the image (e.g. explanation)
    DiagnosticReport.media.link This element is included in summaries. 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.conclusion 0..1 string Clinical conclusion (interpretation) of test results
    DiagnosticReport.conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
    Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
    DiagnosticReport.presentedForm This element must be supported. 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 example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG
    DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()

    This structure is derived from DiagnosticReport

    Summary

    Mandatory: 2 elements(1 nested mandatory element)
    Must-Support: 12 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

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

    Maturity: 5

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    DiagnosticReport.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    DiagnosticReport.identifier This element is included in summaries. 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element is a modifier element. This element must be supported. This element is included in summaries. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. This element is included in summaries. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. This element is included in summaries. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

    DiagnosticReport.code This element must be supported. This element is included in summaries. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. This element is included in summaries. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. This element is included in summaries. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. This element is included in summaries. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media This element is included in summaries. 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    DiagnosticReport.media.link This element is included in summaries. 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.presentedForm This element must be supported. 0..* Attachment Entire report as issued

    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 example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()

    Differential View

    This structure is derived from DiagnosticReport

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.identifier 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element must be supported. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.
    DiagnosticReport.code This element must be supported. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.link 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.presentedForm This element must be supported. 0..* Attachment Entire report as issued

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    DiagnosticReport.status Base required DiagnosticReportStatus 📦4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: doco
    DiagnosticReport C 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
    Constraints: us-core-10
    DiagnosticReport.id This element is included in summaries. 0..1 id Logical id of this artifact
    DiagnosticReport.meta This element is included in summaries. 0..1 Meta Metadata about the resource
    DiagnosticReport.implicitRules This element is a modifier element. This element is included in summaries. 0..1 uri A set of rules under which this content was created
    DiagnosticReport.language 0..1 code Language of the resource content
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding
    DiagnosticReport.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
    DiagnosticReport.contained 0..* Resource Contained, inline Resources
    DiagnosticReport.extension 0..* Extension Additional content defined by implementations
    DiagnosticReport.modifierExtension This element is a modifier element. 0..* Extension Extensions that cannot be ignored
    DiagnosticReport.identifier This element is included in summaries. 0..* Identifier 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Business identifier for report
    DiagnosticReport.basedOn 0..* Reference(US Core ServiceRequest Profile | US Core CarePlan Profile | ImmunizationRecommendation | US Core MedicationRequest Profile | US Core NutritionOrder Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: What was requested
    DiagnosticReport.status This element is a modifier element. This element must be supported. This element is included in summaries. C 1..1 code registered | partial | preliminary | final +
    Binding: DiagnosticReportStatus (required)
    DiagnosticReport.Slices for category This element must be supported. This element is included in summaries. 1..* CodeableConcept Service category
    Slice: Unordered, Open by value:$this
    Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.

    Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
    DiagnosticReport.Slices for category.category:us-core This element must be supported. This element is included in summaries. 0..* CodeableConcept Service category
    Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted in other slices, see Required Bindings When Slicing by Value Sets
    Additional BindingsPurposeDocumentation
    US Core Diagnostic Report Category Codes Min Binding
    Must Support, at a minimum, Cardiology, Radiology, and Pathology category codes.

    DiagnosticReport.code This element must be supported. This element is included in summaries. 1..1 CodeableConcept US Core Report Code
    Binding: US Core Non Laboratory Codes (extensible): LOINC codes
    DiagnosticReport.subject This element must be supported. This element is included in summaries. 1..1 Reference(US Core Patient Profile This type must be supported. | Group | US Core Device Profile | US Core Location Profile) The subject of the report - usually, but not always, the patient
    DiagnosticReport.encounter This element must be supported. This element is included in summaries. 0..1 Reference(US Core Encounter Profile) Encounter associated with DiagnosticReport
    DiagnosticReport.effective[x] This element must be supported. This element is included in summaries. C 0..1 Diagnostically relevant time (typically the time of the procedure)
    DiagnosticReport.effective[x].effectiveDateTime dateTime This target must be supported.
    DiagnosticReport.effective[x].effectivePeriod Period
    DiagnosticReport.issued This element must be supported. This element is included in summaries. 0..1 instant DateTime this version was made
    DiagnosticReport.performer This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile This type must be supported. | US Core PractitionerRole Profile | US Core CareTeam Profile) Responsible Diagnostic Service
    DiagnosticReport.resultsInterpreter This element must be supported. This element is included in summaries. 0..* Reference(US Core Practitioner Profile This type must be supported. | US Core Organization Profile | PractitionerRole | US Core CareTeam Profile) Primary result interpreter
    DiagnosticReport.specimen 0..* Reference(Specimen) Specimens this report is based on
    DiagnosticReport.result This element must be supported. 0..* Reference(US Core Observation Clinical Result Profile This type must be supported. | US Core Laboratory Result Observation Profile | Observation) Observations
    DiagnosticReport.imagingStudy 0..* Reference(US Core ImagingStudy Profile) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to full details of imaging associated with the diagnostic report
    DiagnosticReport.media This element is included in summaries. 0..* BackboneElement 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Key images associated with this report
    DiagnosticReport.media.id 0..1 string Unique id for inter-element referencing
    DiagnosticReport.media.extension 0..* Extension Additional content defined by implementations
    DiagnosticReport.media.modifierExtension This element is a modifier element. This element is included in summaries. 0..* Extension Extensions that cannot be ignored even if unrecognized
    DiagnosticReport.media.comment 0..1 string Comment about the image (e.g. explanation)
    DiagnosticReport.media.link This element is included in summaries. 1..1 Reference(Media) 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Reference to the image source
    DiagnosticReport.conclusion 0..1 string Clinical conclusion (interpretation) of test results
    DiagnosticReport.conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
    Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.
    DiagnosticReport.presentedForm This element must be supported. 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 example Diagnostic Service Section Codes 📍4.0.1 FHIR Std.
    DiagnosticReport.category:us-core Base required US Core Diagnostic Report Category Codes 📦10.0.0-ballot This IG
    DiagnosticReport.code Base extensible US Core Non Laboratory Codes 📦10.0.0-ballot This IG
    DiagnosticReport.conclusionCode Base example SNOMED CT Clinical Findings 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    us-core-10 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()

    This structure is derived from DiagnosticReport

    Summary

    Mandatory: 2 elements(1 nested mandatory element)
    Must-Support: 12 elements

    Structures

    This structure refers to these other structures:

    Slices

    This structure defines the following Slices:

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

    Maturity: 5

     

    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 clinical 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={Patient/}[id]

      Example:

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

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient ( see how to search by reference).

    2. SHALL support searching for all Observations using the combination of the patient and category search parameters

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

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&category=http://loinc.org|LP29708-2

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient and a category code = "LP29708-2" ( see how to search by reference and how to search by token).

    3. SHALL support searching for all Observations by code using the combination of the patient and code search parameters

      • Including optional support OR search on code (e.g.code={system|}[code],{system|}[code],...)

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

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&code=http://loinc.org|45033-8

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

    4. SHALL support searching for all Observations by date using the combination of the patient and category and date search parameters

      • Including optional support for AND search on date (e.g.date=[date]&date=[date]&...)

      • Including support for these date comparators: "gt", "lt", "ge", "le"

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

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&category=http://loinc.org|LP29708-2&date=ge2010-01-14T00:00:00Z

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient and date and a category code = "LP29708-2" ( see how to search by reference and how to search by token and how to search by date).

    Optional Search Parameters:

    The following search parameters and search parameter combinations SHOULD be supported

    1. SHOULD support searching for all reports for a patient by a business identifier using the combination of the patient and identifier search parameters

      GET [base]/DiagnosticReport?patient={Patient/}[id]&identifier={system|}[search_code]

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&identifier=http://example.org/radiology/accession|A20190203001

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient and identifier. This allows a known accession or business identifier to be used to locate the corresponding report. ( see how to search by reference and how to search by token).

    2. SHOULD support searching for all Observations for a patient for a given status (for example completed reports ) using the combination of the patient and status search parameters

      • Including support OR search on status (e.g.status={system|}[code],{system|}[code],...)

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

      Example:

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

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient and status ( see how to search by reference and how to search by token).

    3. SHOULD support searching using the combination of the patient and category and _lastUpdated search parameters

      • Including optional support for AND search on _lastUpdated (e.g._lastUpdated=[date]&_lastUpdated=[date]&...)

      • Including support for these _lastUpdated comparators: "gt", "lt", "ge", "le"

      GET [base]/DiagnosticReport?patient={Patient/}[id]&category={system|}[search_code]&_lastUpdated=[dateTime]

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&category=http://loinc.org|LP29708-2&_lastUpdated=ge2010-01-14T00:00:00Z

      Implementation Notes: Fetches a bundle of all US Core DiagnosticReport Profile for Report and Note Exchange resources for the specified patient and category = "LP29708-2" and _lastUpdated. See the US Core General Guidance page for Searching Using lastUpdated. ( see how to search by reference and how to search by token and how to search by date).

    4. SHOULD support searching for Observations by code and date using the combination of the patient and code and date search parameters

      • Including optional support OR search on code (e.g.code={system|}[code],{system|}[code],...)

      • Including optional support for AND search on date (e.g.date=[date]&date=[date]&...)

      • Including support for these date comparators: "gt", "lt", "ge", "le"

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

      Example:

      1. GET [base]/DiagnosticReport?patient=Patient/1137192&code=http://loinc.org|45033-8&date=ge2019-01-14T00:00:00Z

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