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
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
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 | 0..* | Reference(Observation - Toxicology Lab Result) | The toxicology lab analysis results being reported. | |
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
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 |
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 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:LaboratorySlice | example | Pattern: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:LaboratorySlice | example | Pattern: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
Summary
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 | |
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 | 0..* | Reference(Observation - Toxicology Lab Result) | The toxicology lab analysis results being reported. | |
conclusion | S | 0..1 | string | Clinical conclusion (interpretation) of test results |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
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 |
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 |
Documentation for this format |
Path | Conformance | ValueSet / Code | URI |
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | |
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.category:LaboratorySlice | example | Pattern: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | |
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet / Code | URI | |||
DiagnosticReport.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-status from the FHIR Standard | ||||
DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.category:LaboratorySlice | example | Pattern: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sections from the FHIR Standard | ||||
DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes | ||||
DiagnosticReport.conclusionCode | example | SNOMEDCTClinicalFindingshttp://hl7.org/fhir/ValueSet/clinical-findings from the FHIR Standard |
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
Summary
Must-Support: 3 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron