Cancer Pathology Data Sharing
1.0.1 - STU 1.0.1
Cancer Pathology Data Sharing
1.0.1 - STU 1.0.1
Cancer Pathology Data Sharing, published by HL7 International / Orders and Observations. This guide is not an authorized publication; it is the continuous build for version 1.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/cancer-reporting/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/cancer-reporting/StructureDefinition/us-pathology-composition | Version: 1.0.1 | |||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: USPathologyComposition | ||
This Composition profile represents a Laboratory Report for the Clinical Pathology Data Sharing Implementation Guide.
This Composition contains a lab-report section which has an entry that references a DiagnosticReport. DiagnosticReport.basedOn references the US Pathology ServiceRequest, the DiagnosticReport.specimen references the US Pathology Specimen and the DiagnosticReport.result references US Pathology Grouper Observation (which represent the Sections in the report), which in turn reference the sub-questions of that Section in the report.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition |
0..* | Composition | US Laboratory Report composition | |
  text |
0..1 | Narrative | Narrative text | |
| identifier |
0..1 | Identifier | Report identifier | |
| status |
1..1 | code | Status of the Report | |
 subject |
1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about | |
| encounter |
0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). | |
| author |
1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report | |
| title |
1..1 | string | Laboratory Report | |
| attester |
0..* | BackboneElement | Attests the report accuracy | |
  Slices for section |
1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code | |
   section:lab-report |
1..* | BackboneElement | Composition is broken into sections | |
 title |
0..1 | string | Label for section (e.g. for ToC) Required Pattern: Lab Report Section | |
 code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
 display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |
 entry |
1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | US Laboratory Report composition 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 | |
 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 |
 text |
0..1 | Narrative | Narrative text 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 |
| identifier |
Σ | 0..1 | Identifier | Report identifier ele-1: All FHIR elements must have a @value or children |
| status |
?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children |
| subject |
Σ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). ele-1: All FHIR elements must have a @value or children |
| date |
Σ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
| author |
Σ | 1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report ele-1: All FHIR elements must have a @value or children |
| title |
Σ | 1..1 | string | Laboratory Report ele-1: All FHIR elements must have a @value or children |
 attester |
0..* | BackboneElement | Attests the report accuracy ele-1: All FHIR elements must have a @value or children | |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |
| Slices for section |
C | 1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
 section:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| section:lab-report |
C | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
0..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children Required Pattern: Lab Report Section | |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |
| entry |
C | 1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.section:lab-report.code | example | Pattern: LOINC Code 26436-6("Laboratory Studies (set)")http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-report | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-report | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | US Laboratory Report composition | |||||
| 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.
| |||||
| text |
0..1 | Narrative | Narrative text | |||||
| 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..1 | Identifier | Report identifier | ||||
| status |
?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
| date |
Σ | 1..1 | dateTime | Composition editing time | ||||
| author |
Σ | 1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report | ||||
| title |
Σ | 1..1 | string | Laboratory Report | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
0..* | BackboneElement | Attests the report accuracy | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section |
C | 1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices |
Content/Rules for all slices | |||||||
 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-report |
C | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) Required Pattern: Lab Report Section | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-report.code | example | Pattern: LOINC Code 26436-6("Laboratory Studies (set)")http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:lab-report.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-report.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-report.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-report | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-report | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 2
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | US Laboratory Report composition | |
| text |
0..1 | Narrative | Narrative text | |
| identifier |
0..1 | Identifier | Report identifier | |
| status |
1..1 | code | Status of the Report | |
| subject |
1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about | |
| encounter |
0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). | |
| author |
1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report | |
| title |
1..1 | string | Laboratory Report | |
| attester |
0..* | BackboneElement | Attests the report accuracy | |
| Slices for section |
1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code | |
| section:lab-report |
1..* | BackboneElement | Composition is broken into sections | |
| title |
0..1 | string | Label for section (e.g. for ToC) Required Pattern: Lab Report Section | |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |
| entry |
1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition |
0..* | Composition | US Laboratory Report composition 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 | |
| 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 |
| text |
0..1 | Narrative | Narrative text 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 |
| identifier |
Σ | 0..1 | Identifier | Report identifier ele-1: All FHIR elements must have a @value or children |
| status |
?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children |
| subject |
Σ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). ele-1: All FHIR elements must have a @value or children |
| date |
Σ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
| author |
Σ | 1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report ele-1: All FHIR elements must have a @value or children |
| title |
Σ | 1..1 | string | Laboratory Report ele-1: All FHIR elements must have a @value or children |
| attester |
0..* | BackboneElement | Attests the report accuracy ele-1: All FHIR elements must have a @value or children | |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |
| Slices for section |
C | 1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| section:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| section:lab-report |
C | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
| title |
0..1 | string | Label for section (e.g. for ToC) ele-1: All FHIR elements must have a @value or children Required Pattern: Lab Report Section | |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children Required Pattern: At least the following | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |
| entry |
C | 1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. ele-1: All FHIR elements must have a @value or children |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | |
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | |
| Composition.section:lab-report.code | example | Pattern: LOINC Code 26436-6("Laboratory Studies (set)")http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-report | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-report | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition |
0..* | Composition | US Laboratory Report composition | |||||
| 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.
| |||||
| text |
0..1 | Narrative | Narrative text | |||||
| 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..1 | Identifier | Report identifier | ||||
| status |
?!Σ | 1..1 | code | Status of the Report Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type |
Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(US Core Patient Profile(6.1.0)) | Who and/or what the composition is about | ||||
| encounter |
Σ | 0..1 | Reference(US Core Encounter Profile(6.1.0)) | The healthcare event which this Laboratory Report is about (when test ordered). | ||||
| date |
Σ | 1..1 | dateTime | Composition editing time | ||||
| author |
Σ | 1..* | Reference(US Pathology Related Practitioner Role) | Who and/or what authored the Laboratory Report | ||||
| title |
Σ | 1..1 | string | Laboratory Report | ||||
| confidentiality |
Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester |
0..* | BackboneElement | Attests the report accuracy | |||||
| 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 | ||||
| mode |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time |
0..1 | dateTime | When the composition was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | |||||
| custodian |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
| 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 | ||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] |
1..1 | Target of the relationship | ||||||
| targetIdentifier |
Identifier | |||||||
| targetReference |
Reference(Composition) | |||||||
| event |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| 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 | ||||
| code |
Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period |
Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail |
Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| Slices for section |
C | 1..* | BackboneElement | Composition is broken into sections Slice: Ordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| section:All Slices |
Content/Rules for all slices | |||||||
| 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) | |||||
| code |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 0..* | Reference(Resource) | A reference to data that supports this section | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| section:lab-report |
C | 1..* | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
| 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 | ||||
| title |
0..1 | string | Label for section (e.g. for ToC) Required Pattern: Lab Report Section | |||||
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 26436-6 | |||||
| display |
1..1 | string | Representation defined by the system Fixed Value: Laboratory Studies (set) | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| author |
0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus |
0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text |
C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode |
0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy |
0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| entry |
C | 1..* | Reference(US Pathology Diagnostic Report) | The Sections in the report. | ||||
| emptyReason |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section |
C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| Composition.type | preferred | FHIRDocumentTypeCodeshttp://hl7.org/fhir/ValueSet/doc-typecodesfrom the FHIR Standard | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26from the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1from the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard | ||||
| Composition.section:lab-report.code | example | Pattern: LOINC Code 26436-6("Laboratory Studies (set)")http://hl7.org/fhir/ValueSet/doc-section-codesfrom the FHIR Standard | ||||
| Composition.section:lab-report.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1from the FHIR Standard | ||||
| Composition.section:lab-report.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderfrom the FHIR Standard | ||||
| Composition.section:lab-report.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section, Composition.section:lab-report | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section, Composition.section:lab-report | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | 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 | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 5 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ HL7 International / Orders and Observations. Package hl7.fhir.us.cancer-reporting#1.0.1 based on FHIR 4.0.1. Generated 2024-12-16
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