PACIO Personal Functioning and Engagement Implementation Guide
2.0.0-ballot - STU2 Ballot United States of America flag

PACIO Personal Functioning and Engagement 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-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-pfe/ and changes regularly. See the Directory of published versions

Resource Profile: Personal Functioning and Engagement Diagnostic Report Note Exchange Profile

Official URL: http://hl7.org/fhir/us/pacio-pfe/StructureDefinition/pfe-diagnostic-report-note-exchange Version: 2.0.0-ballot
Active as of 2024-08-13 Computable Name: PFEDiagnosticReportNoteExchange

An exchange of post-acute care diagonistic report notes for a patient. This profile is used for exchanging diagnostic report notes, as opposed to laboratory notes.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) (USCDI) Responsible Diagnostic Service
... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) (USCDI) Observations
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] 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 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (USCDI) 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 SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Must-Support: 3 elements

Differential View

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] 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
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile | US Core Organization Profile) (USCDI) Responsible Diagnostic Service
... result S 0..* Reference(US Core Laboratory Result Observation Profile | US Core Observation Clinical Result Profile) (USCDI) Observations
... media SΣ 0..* BackboneElement (USCDI) Key images associated with this report
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... link SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DiagnosticReport C 0..* USCoreDiagnosticReportProfileNoteExchange A Diagnostic report - a combination of request information, atomic results, images, interpretation, as well as formatted reports
us-core-10: effective[x] 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 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier Σ 0..* Identifier Business identifier for report
... basedOn S 0..* Reference(CarePlan | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) What was requested
... status ?!SΣC 1..1 code (USCDI) registered | partial | preliminary | final +
Binding: DiagnosticReportStatus (required)
... Slices for category SΣ 1..* CodeableConcept (USCDI) Service category
Slice: Unordered, Open by pattern:$this
Binding: DiagnosticServiceSectionCodes (example): Codes for diagnostic service sections.


.... category:us-core SΣ 0..* CodeableConcept (USCDI) Service category
Binding: US Core Diagnostic Report Category Codes (required): Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... code SΣ 1..1 CodeableConcept (USCDI) US Core Report Code
Binding: US Core Non Laboratory Codes (extensible): LOINC codes

... subject SΣ 1..1 Reference(US Core Patient Profile) (USCDI) The subject of the report - usually, but not always, the patient
... encounter SΣ 0..1 Reference(US Core Encounter Profile) (USCDI) Health care event when test ordered
... effective[x] SΣC 0..1 (USCDI) Diagnostically relevant time (typically the time of the procedure)
.... effectiveDateTime dateTime S
.... effectivePeriod Period
... issued SΣ 0..1 instant (USCDI) DateTime this version was made
... performer SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile S | US Core PractitionerRole Profile | US Core CareTeam Profile) (USCDI) Responsible Diagnostic Service
... resultsInterpreter Σ 0..* Reference(Practitioner | PractitionerRole | Organization | CareTeam) Primary result interpreter
... specimen 0..* Reference(Specimen) Specimens this report is based on
... result S 0..* Reference(US Core Laboratory Result Observation Profile S | US Core Observation Clinical Result Profile S | Observation) (USCDI) Observations
... imagingStudy 0..* Reference(ImagingStudy) Reference to full details of imaging associated with the diagnostic report
... media SΣ 0..* BackboneElement (USCDI) 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 SΣ 1..1 Reference(Media) (USCDI) Reference to the image source
... conclusion S 0..1 string Clinical conclusion (interpretation) of test results
... conclusionCode S 0..* CodeableConcept Codes for the clinical conclusion of test results
Binding: SNOMEDCTClinicalFindings (example): Diagnosis codes provided as adjuncts to the report.


... presentedForm S 0..* Attachment (USCDI) Entire report as issued

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
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:us-corerequiredUSCoreDiagnosticReportCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-category
DiagnosticReport.codeextensibleUSCoreNonLaboratoryCodes
http://hl7.org/fhir/us/core/ValueSet/us-core-diagnosticreport-report-and-note-codes
DiagnosticReport.conclusionCodeexampleSNOMEDCTClinicalFindings
http://hl7.org/fhir/ValueSet/clinical-findings
from the FHIR Standard

This structure is derived from USCoreDiagnosticReportProfileNoteExchange

Summary

Must-Support: 3 elements

 

Other representations of profile: CSV, Excel, Schematron