International Patient Summary Implementation Guide
1.1.0 - CI Build International flag

International Patient Summary Implementation Guide, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ips/ and changes regularly. See the Directory of published versions

Resource Profile: DiagnosticReport (IPS)

Official URL: http://hl7.org/fhir/uv/ips/StructureDefinition/DiagnosticReport-uv-ips Version: 1.1.0
Standards status: Trial-use Maturity Level: 2 Computable Name: DiagnosticReportUvIps

This profile constrains the DiagnosticReport resource to represent diagnostic test and procedure reports in a patient summary.

This profile constrains the DiagnosticReport resource to use the specific IPS profiles for observations and coded data types.

Usage:

Formal Views of Profile Content

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

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1 code registered | partial | preliminary | final +
Fixed Value: final
... category S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... effective[x] S 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer S 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Patient (IPS) | Group) The subject of the report - usually, but not always, the patient
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... category S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Patient (IPS) | Group) The subject of the report - usually, but not always, the patient
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusion 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from DiagnosticReport

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... status 1..1 code registered | partial | preliminary | final +
Fixed Value: final
... category S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
.... reference S 1..1 string Literal reference, Relative, internal or absolute URL
... effective[x] S 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer S 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Patient (IPS) | Group) The subject of the report - usually, but not always, the patient
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... performer SΣ 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* DiagnosticReport A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... 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
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!Σ 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required): The status of the diagnostic report.


Fixed Value: final
... category S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


... code S 1..1 CodeableConceptIPS Concept - reference to a terminology or just text
Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.

... subject SΣ 1..1 Reference(Patient (IPS) | Group) The subject of the report - usually, but not always, the patient
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣ 1..1 Clinically relevant time/time-period for report
.... effective[x]:All Types Content/Rules for all Types
..... id 0..1 string Unique id for inter-element referencing
..... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... data-absent-reason S 0..1 code effective[x] absence reason
URL: http://hl7.org/fhir/StructureDefinition/data-absent-reason
Binding: DataAbsentReason (required)
.... effectiveDateTime dateTime
.... effectivePeriod Period
... issued Σ 0..1 instant DateTime this version was made
... performer SΣ 0..* Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen (IPS)) Specimens this report is based on
... Slices for result S 0..* Reference(Observation) Observation results included in the diagnostic report.
Slice: Unordered, Open by profile:resolve()
.... result:observation-results S 0..* Reference(Observation Results: laboratory (IPS) | Observation Results: pathology (IPS) | Observation Results: radiology (IPS) | Observation Results (IPS)) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media Σ 0..* BackboneElement Key images associated with this report
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... comment 0..1 string Comment about the image (e.g. explanation)
.... link Σ 1..1 Reference(Media) Reference to the image source
... conclusion 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm 0..* Attachment Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DiagnosticReport.statusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/diagnostic-report-status|4.0.1
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codepreferredLOINCDiagnosticReportCodes (a valid code from LOINC)
http://hl7.org/fhir/ValueSet/report-codes
from the FHIR Standard
DiagnosticReport.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDiagnosticReportIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDiagnosticReportIf 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-4errorDiagnosticReportIf 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-5errorDiagnosticReportIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDiagnosticReportA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron