Breast Imaging Reporting - 2nd STU ballot, published by HL7 International - Clinical Interoperability Council. This is not an authorized publication; it is the continuous build for version 0.3.0). This version is based on the current content of https://github.com/HL7/fhir-breast-radiology-ig/ and changes regularly. See the Directory of published versions
Draft as of 2019-11-01 |
Definitions for the BreastServiceRequest resource profile.
Guidance on how to interpret the contents of this table can be found here.
1. ServiceRequest | |
2. ServiceRequest.extension | |
Control | 10..* |
Slicing | This element introduces a set of slices on ServiceRequest.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
3. ServiceRequest.extension:breastLaterality | |
SliceName | breastLaterality |
Control | 1..1 |
Type | Extension(BreastLateralityExtension) (Extension Type: CodeableConcept) |
Guidance on how to interpret the contents of this table can be found here.
1. ServiceRequest | |
Definition | - A record of a request for service such as diagnostic investigations, treatments, or operations to be performed. |
Control | 0..* |
Alternate Names | diagnostic request, referral, referral request, transfer of care request |
Comments | - |
Invariants | Defined on this element dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (: contained.contained.empty()) 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 (: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (: contained.meta.security.empty()) dom-6: A resource should have narrative for robust management (: text.`div`.exists()) prr-1: orderDetail SHALL only be present if code is present (: orderDetail.empty() or code.exists()) |
2. ServiceRequest.implicitRules | |
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. |
Control | 0..1 |
Type | uri |
Is Modifier | true |
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
3. ServiceRequest.extension | |
Definition | An Extension May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Control | 10..* |
Type | Extension |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
Slicing | This element introduces a set of slices on ServiceRequest.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
4. ServiceRequest.extension:breastLaterality | |
SliceName | breastLaterality |
Definition | Extension that defines the laterality of the breast being examined. |
Control | 1..1 This element is affected by the following invariants: ele-1 |
Type | Extension(BreastLateralityExtension) (Extension Type: CodeableConcept) |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
5. ServiceRequest.modifierExtension | |
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
Control | 0..* |
Type | Extension |
Is Modifier | true |
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
Alternate Names | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) |
6. ServiceRequest.status | |
Definition | The status of the order. |
Control | 1..1 |
Binding | The codes SHALL be taken from RequestStatus The status of a service order. |
Type | code |
Is Modifier | true |
Must Support | true |
Comments | The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
7. ServiceRequest.intent | |
Definition | Whether the request is a proposal, plan, an original order or a reflex order. |
Control | 1..1 |
Binding | The codes SHALL be taken from RequestIntent The kind of service request. |
Type | code |
Is Modifier | true |
Must Support | true |
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
8. ServiceRequest.category | |
Definition | A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). |
Control | 10..* |
Binding | For example codes, see ServiceRequestCategoryCodes Classification of the requested service. |
Type | CodeableConcept |
Must Support | true |
Requirements | Used for filtering what service request are retrieved and displayed. |
Comments | There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
Slicing | This element introduces a set of slices on ServiceRequest.category. The slices are unordered and Open, and can be differentiated using the following discriminators:
|
9. ServiceRequest.category:us-core | |
SliceName | us-core |
Definition | A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). |
Control | 0..* |
Binding | The codes SHALL be taken from US Core ServiceRequest Category CodesFor example codes, see ServiceRequestCategoryCodes |
Type | CodeableConcept |
Must Support | true |
Requirements | Used for filtering what service request are retrieved and displayed. |
Comments | There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
10. ServiceRequest.doNotPerform | |
Definition | Set this to true if the record is saying that the service/procedure should NOT be performed. |
Control | 0..1 |
Type | boolean |
Is Modifier | true |
Requirements | Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. |
Comments | In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation. |
Meaning if Missing | If missing, the request is a positive request e.g. "do perform" |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
11. ServiceRequest.code | |
Definition | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. |
Control | 10..1 |
Binding | The codes SHALL be taken from US Core Procedure Codes; other codes may be used where these codes are not suitableFor example codes, see ProcedureCodes(SNOMEDCT) |
Type | CodeableConcept |
Must Support | true |
Alternate Names | service requested |
Comments | Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
12. ServiceRequest.subject | |
Definition | On whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). |
Control | 1..1 |
Type | Reference(USCorePatientProfile|Patient|Group|Location|Device) |
Must Support | true |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
13. ServiceRequest.occurrence[x] | |
Definition | The date/time at which the requested service should occur. |
Control | 0..1 |
Type | Choice of: Period, dateTime, Timing |
[x] Note | See Choice of Data Types for further information about how to use [x] |
Must Support | true |
Must Support Types | PerioddateTime |
Alternate Names | schedule |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
14. ServiceRequest.authoredOn | |
Definition | When the request transitioned to being actionable. |
Control | 0..1 |
Type | dateTime |
Must Support | true |
Alternate Names | orderedOn |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
15. ServiceRequest.requester | |
Definition | The individual who initiated the request and has responsibility for its activation. |
Control | 0..1 |
Type | Reference(USCorePractitionerProfile|USCoreOrganizationProfile|USCorePatientProfile|PractitionerRole|USCoreRelatedPersonProfile|Device|Practitioner|Organization|Patient|RelatedPerson) |
Must Support | true |
Must Support Types | Reference(USCorePractitionerProfile) |
Alternate Names | author, orderer |
Comments | This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource. |
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |
Guidance on how to interpret the contents of this table can be found here.
1. ServiceRequest | |||||
Definition | - | ||||
Control | 0..* | ||||
Alternate Names | diagnostic request, referral, referral request, transfer of care request | ||||
Comments | - | ||||
2. ServiceRequest.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Control | 0..1 | ||||
Type | id | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
3. ServiceRequest.meta | |||||
Definition | The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Control | 0..1 | ||||
Type | Meta | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
4. ServiceRequest.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
5. ServiceRequest.language | |||||
Definition | The base language in which the resource is written. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages
A human language
| ||||
Type | code | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
6. ServiceRequest.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
7. ServiceRequest.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
8. ServiceRequest.extension | |||||
Definition | An Extension | ||||
Control | 1..* | ||||
Type | Extension | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
Slicing | This element introduces a set of slices on ServiceRequest.extension. The slices are unordered and Open, and can be differentiated using the following discriminators:
| ||||
9. ServiceRequest.extension:breastLaterality | |||||
SliceName | breastLaterality | ||||
Definition | Extension that defines the laterality of the breast being examined. | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(BreastLateralityExtension) (Extension Type: CodeableConcept) | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
10. ServiceRequest.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) ext-1: Must have either extensions or value[x], not both (: extension.exists() != value.exists()) | ||||
11. ServiceRequest.identifier | |||||
Definition | Identifiers assigned to this order instance by the orderer and/or the receiver and/or order fulfiller. | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Comments | The identifier.type element is used to distinguish between the identifiers assigned by the orderer (known as the 'Placer' in HL7 v2) and the producer of the observations in response to the order (known as the 'Filler' in HL7 v2). For further discussion and examples see the resource notes section below. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
12. ServiceRequest.instantiatesCanonical | |||||
Definition | The URL pointing to a FHIR-defined protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. | ||||
Control | 0..* | ||||
Type | canonical(ActivityDefinition|PlanDefinition) | ||||
Comments | Note: This is a business identifier, not a resource identifier (see discussion). It is best practice for the identifier to only appear on a single resource instance, however business practices may occasionally dictate that multiple resource instances with the same identifier can exist - possibly even with different resource types. For example, multiple Patient and a Person resource instance might share the same social insurance number. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
13. ServiceRequest.instantiatesUri | |||||
Definition | The URL pointing to an externally maintained protocol, guideline, orderset or other definition that is adhered to in whole or in part by this ServiceRequest. | ||||
Control | 0..* | ||||
Type | uri | ||||
Comments | This might be an HTML page, PDF, etc. or could just be a non-resolvable URI identifier. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
14. ServiceRequest.basedOn | |||||
Definition | Plan/proposal/order fulfilled by this request. | ||||
Control | 0..* | ||||
Type | Reference(CarePlan|ServiceRequest|MedicationRequest) | ||||
Alternate Names | fulfills | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
15. ServiceRequest.replaces | |||||
Definition | The request takes the place of the referenced completed or terminated request(s). | ||||
Control | 0..* | ||||
Type | Reference(ServiceRequest) | ||||
Alternate Names | supersedes, prior, renewed order | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
16. ServiceRequest.requisition | |||||
Definition | A shared identifier common to all service requests that were authorized more or less simultaneously by a single author, representing the composite or group identifier. | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Requirements | Some business processes need to know if multiple items were ordered as part of the same "requisition" for billing or other purposes. | ||||
Alternate Names | grouperId, groupIdentifier | ||||
Comments | Requests are linked either by a "basedOn" relationship (i.e. one request is fulfilling another) or by having a common requisition. Requests that are part of the same requisition are generally treated independently from the perspective of changing their state or maintaining them after initial creation. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
17. ServiceRequest.status | |||||
Definition | The status of the order. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from RequestStatus The status of a service order | ||||
Type | code | ||||
Is Modifier | true | ||||
Must Support | true | ||||
Comments | The status is generally fully in the control of the requester - they determine whether the order is draft or active and, after it has been activated, competed, cancelled or suspended. States relating to the activities of the performer are reflected on either the corresponding event (see Event Pattern for general discussion) or using the Task resource. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
18. ServiceRequest.intent | |||||
Definition | Whether the request is a proposal, plan, an original order or a reflex order. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from RequestIntent The kind of service request | ||||
Type | code | ||||
Is Modifier | true | ||||
Must Support | true | ||||
Comments | This element is labeled as a modifier because the intent alters when and how the resource is actually applicable. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
19. ServiceRequest.category | |||||
Definition | A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). | ||||
Control | 1..* | ||||
Binding | For example codes, see ServiceRequestCategoryCodes Classification of the requested service | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Requirements | Used for filtering what service request are retrieved and displayed. | ||||
Comments | There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
Slicing | This element introduces a set of slices on ServiceRequest.category. The slices are unordered and Open, and can be differentiated using the following discriminators:
| ||||
20. ServiceRequest.category:us-core | |||||
SliceName | us-core | ||||
Definition | A code that classifies the service for searching, sorting and display purposes (e.g. "Surgical Procedure"). | ||||
Control | 0..* | ||||
Binding | The codes SHALL be taken from US Core ServiceRequest Category Codes | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Requirements | Used for filtering what service request are retrieved and displayed. | ||||
Comments | There may be multiple axis of categorization depending on the context or use case for retrieving or displaying the resource. The level of granularity is defined by the category concepts in the value set. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
21. ServiceRequest.priority | |||||
Definition | Indicates how quickly the ServiceRequest should be addressed with respect to other requests. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from RequestPriority Identifies the level of importance to be assigned to actioning the request | ||||
Type | code | ||||
Meaning if Missing | If missing, this task should be performed with normal priority | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
22. ServiceRequest.doNotPerform | |||||
Definition | Set this to true if the record is saying that the service/procedure should NOT be performed. | ||||
Control | 0..1 | ||||
Type | boolean | ||||
Is Modifier | true | ||||
Requirements | Used for do not ambulate, do not elevate head of bed, do not flush NG tube, do not take blood pressure on a certain arm, etc. | ||||
Comments | In general, only the code and timeframe will be present, though occasional additional qualifiers such as body site or even performer could be included to narrow the scope of the prohibition. If the ServiceRequest.code and ServiceRequest.doNotPerform both contain negation, that will reinforce prohibition and should not have a double negative interpretation. | ||||
Meaning if Missing | If missing, the request is a positive request e.g. "do perform" | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
23. ServiceRequest.code | |||||
Definition | A code that identifies a particular service (i.e., procedure, diagnostic investigation, or panel of investigations) that have been requested. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from US Core Procedure Codes; other codes may be used where these codes are not suitable | ||||
Type | CodeableConcept | ||||
Must Support | true | ||||
Alternate Names | service requested | ||||
Comments | Many laboratory and radiology procedure codes embed the specimen/organ system in the test order name, for example, serum or serum/plasma glucose, or a chest x-ray. The specimen might not be recorded separately from the test code. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
24. ServiceRequest.orderDetail | |||||
Definition | Additional details and instructions about the how the services are to be delivered. For example, and order for a urinary catheter may have an order detail for an external or indwelling catheter, or an order for a bandage may require additional instructions specifying how the bandage should be applied. | ||||
Control | 0..* This element is affected by the following invariants: prr-1 | ||||
Binding | For example codes, see ServiceRequestOrderDetailsCodes Codified order entry details which are based on order context | ||||
Type | CodeableConcept | ||||
Alternate Names | detailed instructions | ||||
Comments | For information from the medical record intended to support the delivery of the requested services, use the | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
25. ServiceRequest.quantity[x] | |||||
Definition | An amount of service being requested which can be a quantity ( for example $1,500 home modification), a ratio ( for example, 20 half day visits per month), or a range (2.0 to 1.8 Gy per fraction). | ||||
Control | 0..1 | ||||
Type | Choice of: Quantity, Ratio, Range | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Requirements | When ordering a service the number of service items may need to be specified separately from the the service item. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
26. ServiceRequest.subject | |||||
Definition | On whom or what the service is to be performed. This is usually a human patient, but can also be requested on animals, groups of humans or animals, devices such as dialysis machines, or even locations (typically for environmental scans). | ||||
Control | 1..1 | ||||
Type | Reference(USCorePatientProfile) | ||||
Must Support | true | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
27. ServiceRequest.encounter | |||||
Definition | An encounter that provides additional information about the healthcare context in which this request is made. | ||||
Control | 0..1 | ||||
Type | Reference(Encounter) | ||||
Alternate Names | context | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
28. ServiceRequest.occurrence[x] | |||||
Definition | The date/time at which the requested service should occur. | ||||
Control | 0..1 | ||||
Type | Choice of: Period, dateTime, Timing | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Must Support | true | ||||
Must Support Types | Period | ||||
Alternate Names | schedule | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
29. ServiceRequest.asNeeded[x] | |||||
Definition | If a CodeableConcept is present, it indicates the pre-condition for performing the service. For example "pain", "on flare-up", etc. | ||||
Control | 0..1 | ||||
Binding | For example codes, see SNOMEDCTMedicationAsNeededReasonCodes A coded concept identifying the pre-condition that should hold prior to performing a procedure. For example "pain", "on flare-up", etc | ||||
Type | Choice of: boolean, CodeableConcept | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
30. ServiceRequest.authoredOn | |||||
Definition | When the request transitioned to being actionable. | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Must Support | true | ||||
Alternate Names | orderedOn | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
31. ServiceRequest.requester | |||||
Definition | The individual who initiated the request and has responsibility for its activation. | ||||
Control | 0..1 | ||||
Type | Reference(USCorePractitionerProfile|USCoreOrganizationProfile|USCorePatientProfile|PractitionerRole|USCoreRelatedPersonProfile|Device) | ||||
Must Support | true | ||||
Must Support Types | Reference(USCorePractitionerProfile) | ||||
Alternate Names | author, orderer | ||||
Comments | This not the dispatcher, but rather who is the authorizer. This element is not intended to handle delegation which would generally be managed through the Provenance resource. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
32. ServiceRequest.performerType | |||||
Definition | Desired type of performer for doing the requested service. | ||||
Control | 0..1 | ||||
Binding | For example codes, see ParticipantRoles Indicates specific responsibility of an individual within the care team, such as "Primary physician", "Team coordinator", "Caregiver", etc | ||||
Type | CodeableConcept | ||||
Alternate Names | specialty | ||||
Comments | This is a role, not a participation type. In other words, does not describe the task but describes the capacity. For example, “compounding pharmacy”, “psychiatrist” or “internal referral”. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
33. ServiceRequest.performer | |||||
Definition | The desired performer for doing the requested service. For example, the surgeon, dermatopathologist, endoscopist, etc. | ||||
Control | 0..* | ||||
Type | Reference(Practitioner|PractitionerRole|Organization|CareTeam|HealthcareService|Patient|Device|RelatedPerson) | ||||
Alternate Names | request recipient | ||||
Comments | If multiple performers are present, it is interpreted as a list of alternative performers without any preference regardless of order. If order of preference is needed use the request-performerOrder extension. Use CareTeam to represent a group of performers (for example, Practitioner A and Practitioner B). | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
34. ServiceRequest.locationCode | |||||
Definition | The preferred location(s) where the procedure should actually happen in coded or free text form. E.g. at home or nursing day care center. | ||||
Control | 0..* | ||||
Binding | For example codes, see ServiceDeliveryLocationRoleType A location type where services are delivered | ||||
Type | CodeableConcept | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
35. ServiceRequest.locationReference | |||||
Definition | A reference to the the preferred location(s) where the procedure should actually happen. E.g. at home or nursing day care center. | ||||
Control | 0..* | ||||
Type | Reference(Location) | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
36. ServiceRequest.reasonCode | |||||
Definition | An explanation or justification for why this service is being requested in coded or textual form. This is often for billing purposes. May relate to the resources referred to in | ||||
Control | 0..* | ||||
Binding | For example codes, see ProcedureReasonCodes Diagnosis or problem codes justifying the reason for requesting the service investigation | ||||
Type | CodeableConcept | ||||
Comments | This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. Use | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
37. ServiceRequest.reasonReference | |||||
Definition | Indicates another resource that provides a justification for why this service is being requested. May relate to the resources referred to in | ||||
Control | 0..* | ||||
Type | Reference(Condition|Observation|DiagnosticReport|DocumentReference) | ||||
Comments | This element represents why the referral is being made and may be used to decide how the service will be performed, or even if it will be performed at all. To be as specific as possible, a reference to Observation or Condition should be used if available. Otherwise when referencing DiagnosticReport it should contain a finding in | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
38. ServiceRequest.insurance | |||||
Definition | Insurance plans, coverage extensions, pre-authorizations and/or pre-determinations that may be needed for delivering the requested service. | ||||
Control | 0..* | ||||
Type | Reference(Coverage|ClaimResponse) | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
39. ServiceRequest.supportingInfo | |||||
Definition | Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as "ask at order entry questions (AOEs)". This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements. | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Alternate Names | Ask at order entry question, AOE | ||||
Comments | To represent information about how the services are to be delivered use the | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
40. ServiceRequest.specimen | |||||
Definition | One or more specimens that the laboratory procedure will use. | ||||
Control | 0..* | ||||
Type | Reference(Specimen) | ||||
Comments | Many diagnostic procedures need a specimen, but the request itself is not actually about the specimen. This element is for when the diagnostic is requested on already existing specimens and the request points to the specimen it applies to. Conversely, if the request is entered first with an unknown specimen, then the Specimen resource points to the ServiceRequest. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
41. ServiceRequest.bodySite | |||||
Definition | Anatomic location where the procedure should be performed. This is the target site. | ||||
Control | 0..* | ||||
Binding | For example codes, see SNOMEDCTBodyStructures Codes describing anatomical locations. May include laterality | ||||
Type | CodeableConcept | ||||
Requirements | Knowing where the procedure is performed is important for tracking if multiple sites are possible. | ||||
Alternate Names | location | ||||
Comments | Only used if not implicit in the code found in ServiceRequest.code. If the use case requires BodySite to be handled as a separate resource instead of an inline coded element (e.g. to identify and track separately) then use the standard extension procedure-targetBodyStructure. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
42. ServiceRequest.note | |||||
Definition | Any other notes and comments made about the service request. For example, internal billing notes. | ||||
Control | 0..* | ||||
Type | Annotation | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
43. ServiceRequest.patientInstruction | |||||
Definition | Instructions in terms that are understood by the patient or consumer. | ||||
Control | 0..1 | ||||
Type | string | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) | ||||
44. ServiceRequest.relevantHistory | |||||
Definition | Key events in the history of the request. | ||||
Control | 0..* | ||||
Type | Reference(Provenance) | ||||
Comments | This might not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject. | ||||
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count())) |