International Patient Summary Implementation Guide
2.0.0 - STU 2

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 2.0.0 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: 2.0.0
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.

Usages:

- Use this Profile: Bundle (IPS)
- Refer to this Profile: Composition (IPS)
- Examples for this Profile: DiagnosticReport/hemoglobin
- CapabilityStatements using this Profile: IPS Server Capability Statement

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

- Key Elements Table
- Differential Table
- Snapshot Table
- Statistics/References
- All

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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: Diagnostics Report Status Codes - IPS (required)
code | SO Σ | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO Σ | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
reference | SO Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
Slices for effective[x] | SO Σ | 1..1 |  | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectiveDateTime | SO Σ | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
performer | SO Σ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
specimen |  | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on
Slices for result |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DiagnosticReport | 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 | DiagnosticReport | 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 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DiagnosticReport | 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 DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  |  | DiagnosticReport |
status |  | 1..1 | code | registered | partial | preliminary | final + Binding: Diagnostics Report Status Codes - IPS (required)
code | SO | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
reference | SO | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
Slices for effective[x] | SO | 1..1 | dateTime, Period | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effective[x]:effectiveDateTime | SO | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
performer | SO | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
specimen |  | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on
Slices for result |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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: Diagnostics Report Status Codes - IPS (required)
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code | SO Σ | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO Σ | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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 | SO Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
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
Slices for effective[x] | SO Σ | 1..1 |  | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectiveDateTime | SO Σ | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
issued | Σ | 0..1 | instant | DateTime this version was made
performer | SO Σ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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 |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG
DiagnosticReport.category | example | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DiagnosticReport | 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 | DiagnosticReport | 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 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DiagnosticReport | 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 DiagnosticReport

Summary

Mandatory: 3 elements
Must-Support: 7 elements

Structures

This structure refers to these other structures:

- Codeable Concept (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips)
- Patient (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Patient-uv-ips)
- Practitioner (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips)
- PractitionerRole (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/PractitionerRole-uv-ips)
- Organization (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips)
- Specimen (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Specimen-uv-ips)
- Observation Results - Laboratory/Pathology (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-laboratory-pathology-uv-ips)
- Observation Results - Radiology (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-radiology-uv-ips)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.effective[x]
- The element 1 is sliced based on the value of DiagnosticReport.result

Maturity: 2

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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: Diagnostics Report Status Codes - IPS (required)
code | SO Σ | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO Σ | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
reference | SO Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
Slices for effective[x] | SO Σ | 1..1 |  | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectiveDateTime | SO Σ | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
performer | SO Σ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
specimen |  | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on
Slices for result |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DiagnosticReport | 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 | DiagnosticReport | 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 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DiagnosticReport | 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() |

Differential View

This structure is derived from DiagnosticReport

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DiagnosticReport |  |  | DiagnosticReport |
status |  | 1..1 | code | registered | partial | preliminary | final + Binding: Diagnostics Report Status Codes - IPS (required)
code | SO | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
reference | SO | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
Slices for effective[x] | SO | 1..1 | dateTime, Period | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effective[x]:effectiveDateTime | SO | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
performer | SO | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
specimen |  | 0..* | Reference(Specimen (IPS)) | Specimens this report is based on
Slices for result |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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: Diagnostics Report Status Codes - IPS (required)
category | Σ | 0..* | CodeableConcept | Service category Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.
code | SO Σ | 1..1 | CodeableConceptIPS | Name/Code for this diagnostic report Binding: LOINCDiagnosticReportCodes (preferred): Codes that describe Diagnostic Reports.
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
subject | SO Σ | 1..1 | Reference(Patient (IPS) | Group) | The subject of the report - usually, but not always, the patient
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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 | SO Σ C | 1..1 | string | Literal reference, Relative, internal or absolute URL
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
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
Slices for effective[x] | SO Σ | 1..1 |  | Clinically relevant time/time-period for report Slice: Unordered, Open by type:$this
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
effectiveDateTime |  |  | dateTime |
effectivePeriod |  |  | Period |
effective[x]:effectiveDateTime | SO Σ | 0..1 | dateTime | Clinically relevant time/time-period for report
Obligations | Actor
SHOULD:able-to-populate | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
issued | Σ | 0..1 | instant | DateTime this version was made
performer | SO Σ | 0..* | Reference(Practitioner (IPS) | PractitionerRole (IPS) | Organization (IPS) | CareTeam) | Responsible Diagnostic Service
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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 |  | 0..* | Reference(Observation) | Observation results included in the diagnostic report. Slice: Unordered, Open by profile:resolve()
result:observation-results | SO | 0..* | Reference(Observation Results - Laboratory/Pathology (IPS) | Observation Results - Radiology (IPS)) | Observations
Obligations | Actor
SHALL:populate-if-known | Creator (IPS)
SHALL:handle | Consumer (IPS)
SHOULD:display | Consumer (IPS)
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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DiagnosticReport.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DiagnosticReport.status | required | DiagnosticReportStatusUvIps `http://hl7.org/fhir/uv/ips/ValueSet/diagnostics-report-status-uv-ips` From this IG
DiagnosticReport.category | example | DiagnosticServiceSectionCodes `http://hl7.org/fhir/ValueSet/diagnostic-service-sections` From the FHIR Standard
DiagnosticReport.code | preferred | LOINCDiagnosticReportCodes(a valid code from LOINC) `http://hl7.org/fhir/ValueSet/report-codes` From the FHIR Standard
DiagnosticReport.subject.type | extensible | ResourceType `http://hl7.org/fhir/ValueSet/resource-types` From the FHIR Standard
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindings `http://hl7.org/fhir/ValueSet/clinical-findings` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DiagnosticReport | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DiagnosticReport | 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 | DiagnosticReport | 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 | DiagnosticReport | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DiagnosticReport | 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 DiagnosticReport

Summary

Mandatory: 3 elements
Must-Support: 7 elements

Structures

This structure refers to these other structures:

- Codeable Concept (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/CodeableConcept-uv-ips)
- Patient (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Patient-uv-ips)
- Practitioner (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Practitioner-uv-ips)
- PractitionerRole (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/PractitionerRole-uv-ips)
- Organization (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Organization-uv-ips)
- Specimen (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Specimen-uv-ips)
- Observation Results - Laboratory/Pathology (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-laboratory-pathology-uv-ips)
- Observation Results - Radiology (IPS) (http://hl7.org/fhir/uv/ips/StructureDefinition/Observation-results-radiology-uv-ips)

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of DiagnosticReport.effective[x]
- The element 1 is sliced based on the value of DiagnosticReport.result

Maturity: 2

Other representations of profile: CSV, Excel, Schematron