Medicolegal Death Investigation (MDI) FHIR Implementation Guide
3.0.0-draft - CI Build
Medicolegal Death Investigation (MDI) FHIR Implementation Guide
3.0.0-draft - CI Build
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 3.0.0-draft 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: 3.0.0-draft | |||
| Standards status: Trial-use | Maturity Level: 3 | Computable Name: DiagnosticReportToxicologyToMDI | ||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.11.42.7 | ||||
The findings and interpretation of diagnostic tests performed during a death investigation and sent from a forensic toxicology laboratory information management system (LIMS) to an MDI CMS. 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.
Usages:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report Constraints: us-core-8, us-core-9 |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 extension |
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 |
  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) | 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 S | |||
| effectivePeriod |
Period | |||
| issued |
SΣC | 0..1 | instant | When the report was released |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile) | 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-statusFrom the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes |
| 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() | |
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists() | |
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists() |
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report | |
| extension |
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) | The subject of the diagnostic report is the decedent. | |
| performer |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | 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 Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report Constraints: us-core-8, us-core-9 | ||||
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
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) | 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 S | US Core PractitionerRole Profile) | 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 | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom 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-findingsFrom the FHIR Standard |
| 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() | |
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists() | |
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists() |
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:
Maturity: 3
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report Constraints: us-core-8, us-core-9 |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| extension |
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 |
| 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) | 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 S | |||
| effectivePeriod |
Period | |||
| issued |
SΣC | 0..1 | instant | When the report was released |
| performer |
SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core PractitionerRole Profile) | 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-statusFrom the FHIR Standard | |
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | |
| DiagnosticReport.code | extensible | USCoreDiagnosticReportLabCodeshttp://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-lab-codes |
| 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() | |
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists() | |
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists() |
Differential View
This structure is derived from USCoreDiagnosticReportProfileLaboratoryReporting
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DiagnosticReport |
0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report | |
| extension |
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) | The subject of the diagnostic report is the decedent. | |
| performer |
0..* | Reference(US Core Practitioner Profile | US Core PractitionerRole Profile) | 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 | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DiagnosticReport |
C | 0..* | USCoreDiagnosticReportProfileLaboratoryReporting | Forensic toxicology report Constraints: us-core-8, us-core-9 | ||||
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
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) | 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 S | US Core PractitionerRole Profile) | 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 | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| DiagnosticReport.status | required | DiagnosticReportStatushttp://hl7.org/fhir/ValueSet/diagnostic-report-statusFrom the FHIR Standard | ||||
| DiagnosticReport.category | example | DiagnosticServiceSectionCodeshttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom the FHIR Standard | ||||
| DiagnosticReport.category:LaboratorySlice | example | Pattern Value: LABhttp://hl7.org/fhir/ValueSet/diagnostic-service-sectionsFrom 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-findingsFrom the FHIR Standard |
| 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() | |
| us-core-8 | error | DiagnosticReport | effective[x] SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies effective.exists() | |
| us-core-9 | error | DiagnosticReport | issued SHALL be present if the status is 'partial', 'preliminary', 'final', 'amended', 'corrected' or 'appended' : (status='partial' or status='preliminary' or status='final' or status='amended' or status='corrected' or status='appended' ) implies issued.exists() |
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:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Public Health. Package hl7.fhir.us.mdi#3.0.0-draft based on FHIR 4.0.1. Generated 2025-07-03
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