Medicolegal Death Investigation (MDI) FHIR Implementation Guide
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Medicolegal Death Investigation (MDI) FHIR Implementation Guide, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.0-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-mdi-ig/ and changes regularly. See the Directory of published versions

Resource Profile: DiagnosticReport - Toxicology Lab Result to MDI

Official URL: http://hl7.org/fhir/us/mdi/StructureDefinition/DiagnosticReport-toxicology-to-mdi Version: 2.0.0-cibuild
Active as of 2024-10-07 Computable Name: DiagnosticReportToxicologyToMDI
Other Identifiers: OID:2.16.840.1.113883.4.642.40.11.42.7

This profile contains constraints to the US Core Diagnostic Report Profile to address the use case for sending data from a forensic toxicology laboratory information management system to an MDI information management system. Each analyzed specimen, represented by a Specimen - Toxicology Lab resource, must be referenced by at least one Observation - Toxicology Lab Result and may be referenced by more than one Observation - Toxicology Lab Result. For specimens received but not analyzed, the laboratory should provide a reason for no analysis in the DiagnosticReport.conclusion and/or each unanalyzed specimen’s Specimen - Toxicology Lab Specimen.note.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1)
... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... subject 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... performer 0..* Reference(US Core Practitioner Profile(5.0.1) | US Core PractitionerRole Profile(5.0.1)) Responsible Diagnostic Service
... result 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
us-core-9: issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime
... issued SΣC 0..1 instant When the report was released
... performer SΣ 0..* Reference(US Core Practitioner Profile(5.0.1)) Responsible Diagnostic Service
... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
us-core-9: issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... 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-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... 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 ?!SΣC 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant When the report was released
... performer SΣ 0..* Reference(US Core Practitioner Profile(5.0.1) S | US Core PractitionerRole Profile(5.0.1)) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... 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 S 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.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Differential View

This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1)
... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... subject 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... performer 0..* Reference(US Core Practitioner Profile(5.0.1) | US Core PractitionerRole Profile(5.0.1)) Responsible Diagnostic Service
... result 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
us-core-9: issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Extension-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime
... issued SΣC 0..1 instant When the report was released
... performer SΣ 0..* Reference(US Core Practitioner Profile(5.0.1)) Responsible Diagnostic Service
... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DiagnosticReport.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileLaboratoryReporting(5.0.1) A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-8: effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
us-core-9: issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended'
... 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-tracking-number S 0..* Identifier A tracking number, such as a case number or file number assigned by a case management system or EDRS.
URL: http://hl7.org/fhir/us/mdi/StructureDefinition/Extension-tracking-number
... 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 ?!SΣC 1..1 code registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:LaboratorySlice SΣ 1..1 CodeableConcept Service category
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.



Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0074
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: LAB
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... code SΣ 1..1 CodeableConcept US Core Laboratory Report Order Code
Binding: US Core Diagnostic Report Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile(5.0.1)) The subject of the diagnostic report is the decedent.
... encounter Σ 0..1 Reference(Encounter) Health care event when test ordered
... effective[x] SΣC 0..1 Diagnostically relevant time (typically the time of specimen collection)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣC 0..1 instant When the report was released
... performer SΣ 0..* Reference(US Core Practitioner Profile(5.0.1) S | US Core PractitionerRole Profile(5.0.1)) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen S 0..* Reference(Specimen - Toxicology Lab) The specimen sent by a Medical Examiner, Coroner, or autopsy performer to the toxicology lab for analysis.
... result S 0..* Reference(Observation - Toxicology Lab Result) The toxicology lab analysis results being reported.
... 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 S 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.statusrequiredDiagnosticReportStatus
http://hl7.org/fhir/ValueSet/diagnostic-report-status
from the FHIR Standard
DiagnosticReport.categoryexampleDiagnosticServiceSectionCodes
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.category:LaboratorySliceexamplePattern: LAB
http://hl7.org/fhir/ValueSet/diagnostic-service-sections
from the FHIR Standard
DiagnosticReport.codeextensibleUSCoreDiagnosticReportLabCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron